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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206858
Report Date: 09/10/2021
Date Signed: 09/10/2021 03:06:46 PM

Document Has Been Signed on 09/10/2021 03:06 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 CARE 3FACILITY NUMBER:
107206858
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2822 CALIMYRNA AVETELEPHONE:
(559) 213-7251
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:COLIN MURCHISON, DESIGNEE REPRESENTATIVETIME COMPLETED:
01:15 PM
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On 09/10/2021, Licensing Program Analysts (LPA) Mai 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 Leizel Jugal. Caregiver call Administrator David Murchison authorized. Colin Murchison, designee representative to conduct tour. Colin arrived later during tour. All six residents were present during the inspection.

During this inspection a tour of the facility was conducted: Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. Passageways were free from obstruction inside and out. No fire hazards observed. Fire extinguisher was charged and service date of 01/22/21. Smoke alarms and carbon monoxide detectors operational. Kitchen toured, LPA observed a 14- day supply of nonperishable food and a 2-day supply of perishable food which were stored properly. LPA observed 30-day medication supply and stored in a locked cabinet in kitchen. Common and resident bathroom tour and sinks are well stocked with liquid soap for hand washing Securely fastened grab bars and non-skid mats in all tub/shower areas. Adequate linen supply observed in hall cabinets. Cleaning supplies were stored and locked in garage. The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed sufficient seating outside.

LPAs did not observe 30-day PPE. Required postings to encourage face coverings observed. Hand washing posting were not observed. Licensee will email LPA to confirmation of PPE supplies stocked and hand washing posting.

No deficiencies issued during this inspection.

Exit Interview conducted. The following updated forms were requested: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities for The Elderly, LIC 9020 Register of Facility Clients/Residents, updated Liability Insurance, LIC 309 Administrative Organization, Administrator Certificate, current Liability Insurance, copy of Administrator Certificate and current lease agreement. Please submit the above forms/information to Fresno CCL by: 09/17/21.

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.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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