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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206601
Report Date: 06/15/2021
Date Signed: 06/15/2021 03:08:34 PM

Document Has Been Signed on 06/15/2021 03:08 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:A PLACE CALLED HOME RESIDENTIAL CAREFACILITY NUMBER:
107206601
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2827 CALIMYRNA AVETELEPHONE:
(559) 322-4432
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Administrator, David MurchisonTIME COMPLETED:
11:30 AM
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On 06/15/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to speak with the Administrator. Facility staff contacted Administrator. Administrator, David Murchison arrived a short time later. Facility has one entry and one exit point. Visitor check-in/screening was observed upon entry to the facility.

LPA conducted a tour of the facility with Administrator. Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was available to residents and visitors. LPA did not observe signs promoting hand-washing, social distancing, or cough and sneeze etiquette. LPA observed resident bedrooms. Beds in the shared bedroom were observed to be at lease 6 feet apart. Bathrooms were stocked with liquid soap and paper towels.

Facility has a 30 day supply of medications. Facility has an adequate supply of food. Additional PPE supplies is kept off-site. Staff records were reviewed for good health and infection control training. Facility staff observed to be wearing facial coverings. Resident records were reviewed. Resident records have updated emergency contact information.

No deficiencies issued during this inspection.

An exit interview was conducted with Administrator. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Administrator was informed to select yes when prompted to send a read receipt. Facility Representative signature on file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2021
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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