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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203409
Report Date: 09/15/2021
Date Signed: 09/15/2021 02:20:04 PM

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:BAGHETTI-HOMEFACILITY NUMBER:
107203409
ADMINISTRATOR:BAGHETTI-ESCALANLE,ROXANNAFACILITY TYPE:
735
ADDRESS:2737 NORWICH AVENUETELEPHONE:
(559) 346-1232
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Roxanna Baghetti-Escalanle, Administrator TIME COMPLETED:
09:55 AM
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On 09/15/2021, Licensing Program Analysts (LPA) M. Yang and A. Walton arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPAs introduced self, stated the purpose of the visit and requested to meet with the Administrator. Upon entry staff was observed not wearing facial covering. Roxanna Baghetti-Escalante, administrator arrived in a short time later and conduct tour with LPAs. Two residents were present during the tour. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. LPAs observed cough etiquette signs and social distancing. All bathrooms are observed with trash cans with lid. LPAs observed hand washing posting by bathroom sinks. LPAs observed residents’ bed in shared bedroom to be at least 3 feet apart with head to toe orientation.

LPAs checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and there appeared to be an adequate supply. Fire extinguisher observed to be last serviced 09/03/2021. Staff records were reviewed for good health and infection control training. A sample of residents have updated emergency contact information.

No deficiencies issued during this inspection.

Exit interview was conducted. Please submit the following forms/information to Fresno CCL by: 09/29/21.


Requested forms/ information: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610D Emergency Disaster Plan for Residential Care Facilities for The Elderly, LIC 9020 Register of Facility Clients/Residents, updated Liability Insurance, LIC 309 Administrative Organization, current Administrator Certification LIC 400 Affidavit Regarding Client/Resident Cash Resources and LIC 402 Surety Bond. Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this email. Report signed on-site
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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