<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202514
Report Date: 10/11/2021
Date Signed: 10/11/2021 02:43:11 PM

Document Has Been Signed on 10/11/2021 02:43 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:RENDERCAREFACILITY NUMBER:
107202514
ADMINISTRATOR:FLAUTA, VICTOR S.FACILITY TYPE:
740
ADDRESS:47 W. MENLO AVE.TELEPHONE:
(559) 325-6909
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 5DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nancy Wade, CaregiverTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/11/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPA was met by Caregiver Nancy Wade. Jill Stowell, Administrator was called by caregiver. Administrator states unable to meet with LPA due to quarantine. Administrator authorized caregiver Nancy Wade to conduct visit and sign report with LPA. All five residents were present during the inspection.

LPA conducted tour with caregiver. Facility staffs was observed with mask on. 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. All bathrooms are observed with trash cans with lid and securely fastened grab bars. Bathrooms have non-skid mat. LPA observed hand washing posting by all sinks. Social distancing and cough etiquette postings observed in facility.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 1 shared resident’s bedroom to be at least 6 feet apart and 3 bedrooms that are single occupant. LPA checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked under kitchen sink and in garage cabinet. The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed fire extinguisher served date: 04/16/21. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. Administrator and caregiver was informed that as COVID-19 precautionary measure, this report will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1