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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206937
Report Date: 07/23/2021
Date Signed: 07/23/2021 11:51:58 AM

Document Has Been Signed on 07/23/2021 11:51 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:BACKER SENIOR CAREHOMEFACILITY NUMBER:
107206937
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:9127 N BACKER AVETELEPHONE:
(559) 721-5483
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 6CENSUS: 6DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Arlene Bautista, AdminstratorTIME COMPLETED:
11:55 AM
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 07/23/2021, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to speak with the Administrator. Administrator, Arlene Bautista, was contacted via telephone and arrived a short time later. LPA disclosed the purpose of the visit with Administrator. The facility has one central entry and exit. Upon entry to the facility, LPA observed visitor log-in/screening.

Facility tour conducted with Administrator. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette throughout facility. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA observed an adequate supply of food. Facility receives grocery delivery every 2 weeks. LPA observed a 30 day supply of PPE and cleaning supplies. Hand-sanitizer is readily available.

Facility has 4 bedrooms, 2 bedrooms are single occupant and 2 bedrooms are double occupant. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs were not observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply. Resident temperature checks are documented daily. Resident records have updated emergency contact information. Facility staff records reviewed for good health and infection control training. Administrator certificate is current.

No deficiencies issued during this inspection.

Exit interview conducted. 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 informed to select yes when prompted to send read receipt. Facility Representative signature on file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
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