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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208764
Report Date: 07/30/2021
Date Signed: 07/30/2021 11:21:20 AM

Document Has Been Signed on 07/30/2021 11:21 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:WILLIAM'S RESIDENTIAL CARE FOR THE ELDERLY LLCFACILITY NUMBER:
107208764
ADMINISTRATOR:RUNDERSON, MARTHA MFACILITY TYPE:
740
ADDRESS:2909 EAST GRIFFITH WAYTELEPHONE:
(559) 226-1082
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY: 3CENSUS: 1DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Administrator, Martha RundersonTIME COMPLETED:
11:18 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
Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator, Martha Runderson, and discussed the purpose of the visit.

LPA Williams toured the facility with the Administrator. No residents were present.

LPA Williams observed a visitor/temperature log, thermometer, masks, and disinfection station at the front entrance. Facility has one entry and exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies and medication were observed behind a locked door. LPA Williams observed the following personal protective equipment in storage; masks, gloves, gowns face shields.

LPA Williams observed staff training records regarding Covid-19 mitigation and infection control. LPA Williams observed facility staff wearing masks. Resident’s file has updated emergency contact information.

No deficiencies cited at this time.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2021
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 3