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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209072
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:41:44 PM

Document Has Been Signed on 07/24/2024 03:41 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:VILLA GUEST HOMEFACILITY NUMBER:
107209072
ADMINISTRATOR/
DIRECTOR:
ALEGRE, AMOR A.FACILITY TYPE:
740
ADDRESS:794 N. VILLA AVENUETELEPHONE:
(559) 369-9949
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 4CENSUS: 3DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:49 AM
MET WITH:Licensee, Amor AlegraTIME VISIT/
INSPECTION COMPLETED:
02:01 PM
NARRATIVE
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On 7/24/24, Licensing Program Analyst (LPA) D. Williams arrived at the facility unannounced to conduct a required Annual Inspection visit. LPA introduced himself, stated purpose of visit, and was allowed entrance by Licensee .

LPA toured the inside of the facility including entry, kitchen, dining, living room, bedrooms, & bathrooms. Facility thermostat reflected 72 degrees Fahrenheit. All fire exit routes were free and clear of obstruction. LPA observed medications are stored in a locked cabinet. Knives and sharp objects are secured.

Facility has 4 bedrooms and 4 bathrooms. All rooms and had required linens, required furniture, and were clean and in good repair. The bathrooms all had grab bars and non-slip mats available for resident use.

Licensee has fire extinguisher and is in good standing. Smoke detectors were present and operational Carbon monoxide detector was tested and in working condition.

LPA reviewed 3 resident files and 2 employee files. All employee files had documents requested by the LPA. 1 of 3 resident files did not have a recorded Tuberculosis test. Licensee stated she will get a copy of the TB test and provide to the Department.

A deficiency is being issued per the California Code of Regulations Title 22 on the attached LIC809D page.

Plan of correction was discussed and reviewed.

An exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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
Document Has Been Signed on 07/24/2024 03:41 PM - It Cannot Be Edited


Created By: Darius Williams On 07/24/2024 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VILLA GUEST HOME

FACILITY NUMBER: 107209072

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Serigy Pidgirny
LICENSING EVALUATOR NAME:Darius Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
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