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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206901
Report Date: 02/04/2022
Date Signed: 02/04/2022 02:49:03 PM

Document Has Been Signed on 02/04/2022 02:49 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 4FACILITY NUMBER:
107206901
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2842 CALIMYRNA AVETELEPHONE:
(559) 326-0953
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Collin Murchison, DesigineeTIME COMPLETED:
01:00 PM
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On 02/04/22, 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 administrator. LPA met with April Rose Salise and Monet Mark Sababo, caregiver. LPA toured facility with caregiver. Collin Murchison, designated representative was called and arrived shortly during tour. All six residents were present during the inspection.

Upon entry facility staff was observed with no mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings not observed.

LPA checked residents’ locked medications. Per designated representative 30-day PPE supplies stored at facility central location. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage and under kitchen sink.

All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 6 bedrooms that are single occupant.

The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed fire extinguisher served date: 01/22/21. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 02/11/22. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 808, and lease agreement. LPA received copy updated Lic 9020 during facility inspection.

Designated representative was informed that as COVID-19 precautionary measure, this report and appeal rights will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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Document Has Been Signed on 02/04/2022 02:49 PM - It Cannot Be Edited


Created By: Mai Yang On 02/04/2022 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: A PLACE CALLED HOME RESIDENTIAL CARE 4
FACILITY NUMBER: 107206901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)
87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Fire Extinguisher has a service date of 01/22/2021, which poses an immediate health and safety risk to the residents
POC Due Date: 02/05/2022
Plan of Correction
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Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 02/05/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022


LIC809 (FAS) - (06/04)
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