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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208807
Report Date: 08/02/2021
Date Signed: 08/02/2021 02:48:40 PM

Document Has Been Signed on 08/02/2021 02:48 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:MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCOFACILITY NUMBER:
107208807
ADMINISTRATOR:BRICE, NASTASSHAFACILITY TYPE:
740
ADDRESS:149 OAK AVENUETELEPHONE:
(559) 298-7906
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 0DATE:
08/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Phoeun Marez, Administrator TIME COMPLETED:
02:55 PM
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 08/02/2021, Licensing Program Analysts (LPAs) A. Walton and M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPAs introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPAs meet with Administrator, Phoeun Marez.

There are currently no residents or staff at the facility. Residents were relocated to another facility in May, 2021 (exact date unknown at this time). LPAs are requesting a plan be submitted to the Fresno CCL Office by 08/06/2021. The plan will include the following: Move out dates for residents, where residents were relocated to, reason why residents were relocated, and when will residents return to the facility.

LPAs conducted a facility tour with Administrator. Facility is currently being remodeled. All entrances and exit were clear from obstructions. No fire clearance issues observed. LPAs observed a small amount PPE supplies. Per Administrator, PPE and cleaning supplies are located at a different facility due to the remodel. Facility has a 7-day supply of non-perishable foods, 2-day supply of perishable not observed. LPAs observed signs promoting social distancing, cough/sneeze etiquette, and hand-washing in the facility. Facility has 5 bedrooms, with 1 shared bedroom.

No deficiencies issued during this inspection.

Exit interview was conducted. Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2021
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