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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208943
Report Date: 07/14/2021
Date Signed: 07/14/2021 01:49:56 PM

Document Has Been Signed on 07/14/2021 01:49 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:DIGNITY GARDENS HOME IIFACILITY NUMBER:
107208943
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:2814 RIALTO AVETELEPHONE:
(559) 917-0440
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 0DATE:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Licensee Camalah KopaczTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Annual Inspection visit. LPA Williams met with Licensee Camalah Kopacz and discussed the purpose of the visit.

Licensee reported there have been no residents admitted to the facility since 7/11/2019.

LPA Williams toured the facility with the Licensee.

LPA Williams observed a visitor log, temperature check, and disinfection station at the front entrance. Licensee has PPE available for future staff.

The common areas can accommodate for social distancing as needed. Beds had at least 6 feet of space between them.

Cleaning supplies were observed behind a locked cabinet and there is a locked cabinet designated for medication.

LPA Williams observed staff training records regarding Covid-19 mitigation and infection control.

No deficiency cited at this time.

An 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: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2021
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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