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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209302
Report Date: 04/10/2023
Date Signed: 04/10/2023 09:04:27 PM

Document Has Been Signed on 04/10/2023 09:04 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:VELA SUITESFACILITY NUMBER:
107209302
ADMINISTRATOR:GRICE, SASHEILAFACILITY TYPE:
740
ADDRESS:6572 NORTH MARIPOSA ST.TELEPHONE:
(559) 438-0980
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 4DATE:
04/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sasheila Grice Applicant/Licensee (L);TIME COMPLETED:
09:30 PM
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An Pre-Licensing visit was conducted on the time & date by Licensing Program Manager (LPA) K. McClurg. LPM met with Sasheila Grice Applicant/Licensee (L).

Facility phone: (559) 438-0980.
Physical plant toured. Interior & exterior passageways free of obstructions. Sufficient lighting & furnishings in dining, living, & resident bedrooms. Locked centralized storage area for medications. First aid kit complete. Hot water tested & measured at 119 degrees F in front hall bathrooms. Physical plant is consistent with the facility sketch/floor plan.
Fire extinguisher service date: 12/19/2022. Smoke & carbon monoxide detectors tested & observed to be operational.

Component III conducted. Regulations & requirements reviewed in additional detail regarding:
  • Staff transfer & verification of association process reviewed, including use of Guardian;
  • Reporting requirements;
  • Resident paperwork file updates in connection with change of ownership (CHOW).
  • Medication paperwork (MARs & CSMDR);
  • Admission Agreement to be used;

Pre-Licensing is incomplete due to issues that require correction prior to licensing. Outstanding issues to be resolved no later than Monday, April 17, 2023**. A follow up Pre-licensure LIC809 will be generated upon resolution of outstanding issues.
**LPA to be contacted prior to due date above that all items reviewed with applicant have been resolved.

Exit interview conducted with L. Report provided at time of visit.
Results of visit emailed to CAB LPA @ time of visit.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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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