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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208812
Report Date: 09/14/2021
Date Signed: 09/14/2021 03:44:16 PM

Document Has Been Signed on 09/14/2021 03:44 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:CATUIRA HOMEFACILITY NUMBER:
107208812
ADMINISTRATOR:MARIA A RECENOFACILITY TYPE:
740
ADDRESS:712 FILBERT AVETELEPHONE:
(559) 299-7167
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Dianne Receno, Administrator and Johnernest Gloria, caregiver TIME COMPLETED:
01:00 PM
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On 09/14/2021, Licensing Program Analysts (LPA) M. Yang and A. Walton arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPAs introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with caregiver Johnernest Gloria. Caregiver call Administrator. LPAs conduct tour with caregiver. Dianne Receno, designee representative arrived later during tour. All four residents were present during the tour. 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. All bathrooms are observed with trash cans with lid. LPAs observed no hand washing posting by bathroom sinks. LPAs observed residents’ bed to be at least 6 feet apart.

LPAs checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and there appeared to be an adequate supply. Fire extinguisher observed to be last serviced 04/16/2021. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. All residents have updated emergency contact information.

No deficiencies issued during this inspection.

Exit interview was conducted. Please submit the above forms/information to Fresno CCL by: 09/28/21. Due to COVID-19 precautionary measures, The following updated forms were requested: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities for The Elderly, LIC 9020 Register of Facility Clients/Residents, updated Liability Insurance, LIC 309 Administrative Organization, LIC 808, LIC 400 and LIC 402. Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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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