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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206935
Report Date: 10/22/2021
Date Signed: 10/22/2021 10:30:08 AM

Document Has Been Signed on 10/22/2021 10:30 AM - 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:FRESNO GUEST HOME XFACILITY NUMBER:
107206935
ADMINISTRATOR:KUTNERIAN, NAZELIFACILITY TYPE:
740
ADDRESS:6590 N JACKSON AVENUETELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 6DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:JayCee Sanderson, Administrator CoordinatorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. Administrator Nazeli Kutnerian was unavailable. Administrator Coordinator JayCee Sanderson was designated to meet with LPA. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. 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. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathroom sink. Bedrooms were checked and beds are six feet apart. The exterior tour was conducted.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Administrator certification is current.

No deficiencies were observed. Exit interview was conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: FRESNO GUEST HOME X
FACILITY NUMBER: 107206935
VISIT DATE: 10/22/2021
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 11/05/2021.

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC809 (FAS) - (06/04)
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