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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208812
Report Date: 09/14/2022
Date Signed: 09/14/2022 11:02:12 AM

Document Has Been Signed on 09/14/2022 11:02 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: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:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Dianne Receno, AdministratorTIME COMPLETED:
11:00 AM
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On 9/14/22, Licensing Program Analysts (LPAs) M. Yang and B. Miranda arrived unannounced to conduct an Annual Inspection - Infection Control. LPAs introduced self, stated the purpose of the visit, and requested to meet with administrator. LPAs met with William Lacambra and Maria Receno. LPA conducted tour with caregiver. Dianne Receno, Administrator was called and arrived shortly during tour. Two residents were present during the inspection.

Upon entry facility staffs was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed.

LPAs checked residents’ locked medications. LPAs observed small amount of PPE supplies in facility. 30 days PPE supplies storage in a central location. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage. LPAs observed fire extinguisher served date: 02/18/22. All resident’s room toured and observed to be adequately furnished and lit. LPAs observed 1 shared residents’ bed to be at least 6 feet apart and 2 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. The exterior tour was conducted. Side gate was self-closing. Outside free of debris. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 9/20/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610E, Lic 9282, control of property, Administrator certificate and current liability insurance. Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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