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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209463
Report Date: 02/04/2025
Date Signed: 02/04/2025 09:13:02 PM

Document Has Been Signed on 02/04/2025 09:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:VILLAGE AT MILL CREEKFACILITY NUMBER:
547209463
ADMINISTRATOR/
DIRECTOR:		BADOUD, ANDREWFACILITY TYPE:
740
ADDRESS:2948 & 2950 E DOUGLAS AVETELEPHONE:
5596256001
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 59CENSUS: 16DATE:
02/04/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Senior Executive Director (SrED) Trevin Willis; Assistant Executive Director (AED) Amanda Chairez; TIME VISIT/
INSPECTION COMPLETED:
09:00 PM
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An unannounced Pre/Comp III visit was conducted by Licensing Program Analyst (LPA) K. McClurg. LPA entered main building (2924 Building 1) with front desk & office. LPA met with. LPA inquired who was Administrator & if they were on-site / available & was told that they were, were in meeting, would notify them that Licensing was on the premises. Business card provided. LPA met with Senior Executive Director (SrED) Trevin Willis & Assistant Executive Director (AED) Amanda Chairez. LPA introduced self, stated purpose of visit, & was allowed entry.

Facility main telephone number: (559) 625-6001

Facility consists of:
-2950 Building A (Bldg A) - Reception desk & resident basic Assisted Living;
-2950 Building B (Bldg B) - Administrative Office & resident Memory Care AL;currently no residents. To notify Community Care Licensing when decide to place residents here.
-2948 Building C (Bldg C) - Front House; currently no residents. To notify Community Care Licensing when decide to place residents here.

All buildings fire cleared for non-ambulatory.
Hospice waiver granted for twelve (12) residents total for facility.
Bldg C limited to a capacity total of six (6) residents.

Fireplaces:
-2950 Bldg A & B: have non-wood burning fireplace. Starter not accessible
-2948 Bldg C has gas fireplace with cover over gas on/off with key.


Continued.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VILLAGE AT MILL CREEK
FACILITY NUMBER: 547209463
VISIT DATE: 02/04/2025
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Continued.

Facility has no bodies of water such as pool, spa, fountains in use. Facility grounds appeared to be neat, tidy, & well maintained.

Delayed egress set to 15 seconds, located at south end of Bldg B, end closest to street.

All Buildings toured.
2950 Bldg A toured. Bldg A observed to appear clean, safe, & in good condition. Hallways & front entryway clear & free of obstruction. Dining/recreation area sufficiently furnished with adequate lighting. Resident bedrooms appeared to be clean, safe, in good condition with no unpleasant odors. Sufficiently furnished with adequate lighting. Resident restrooms toured. Grab bars in all toilet & shower areas. Hot water measured throughout facility between 105 & 117. Kitchen toured. Appeared to be clean & maintained. Perishable & non-Perishable food available. Refrigerator/freezer appeared to be clean & set at appropriate temperatures. Additional food kept @ Bldg B in larger kitchen.

2950 Bldg B toured. No residents currently in Bldg B. Bldg B currently being remodeled & not in use. SrED has agreed to contact CCL & wait for inspection prior to placing residents in building.

2948 Bldg C toured. No residents currently in Bldg C. Bldg C in process Admin assignment changes. SrED has agreed to contact CCL & wait for inspection prior to placing residents in building.

Fire extinguisher service date 11/20/2024. Facility fire/ smoke & carbon monoxide detectors are tested, maintained, & serviced by Fire Solutions. Pull cord alert signals in all 3 buildings with a centralized notification area in each building. Signal system operational & maintained by facility through manual pull test.

Continued.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VILLAGE AT MILL CREEK
FACILITY NUMBER: 547209463
VISIT DATE: 02/04/2025
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Continued.

Resident & personal records available. Medications for entire facility maintained in medication room. Centrally Stored Medication & Destruction Records (CSMDR) & Medication Administration Record (MARs) present & appropriately maintained.
Component III conducted during this visit.

Exit interview conducted with SrED & AED. Report provided.

"Pre-Licensing is complete and this facility has no deficiencies."
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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