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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209378
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:10:03 PM

Document Has Been Signed on 11/19/2024 02:10 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ATTENTIVE SENIOR CARE III, LLCFACILITY NUMBER:
107209378
ADMINISTRATOR/
DIRECTOR:
HOLLAND, PAULETTEFACILITY TYPE:
740
ADDRESS:85 W ATHENS AVE.TELEPHONE:
(559) 940-7065
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 0DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Licensee: Lawrence HollandTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 11/19/24 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Licensee (L1) Lawrence Holland. LPA was granted entry. 0 clients are currently not placed in facility. Administrator Paulette Holland (A1) arrived shortly after LPA’s arrival.

LPA toured facility with L1 and A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. No food was observed in refrigerator or freezer because of no residents in facility. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 37 degrees F. Cleaning chemicals was observed stored and locked under kitchen sink. Fire extinguisher was observed with a service date of: 2/8/23. Fire drill currently not conducted because of vacancy of residents in facility. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested 114.2 degrees F in bathroom 1 and 118.4 degrees F in bathroom 2. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Medications not present in facility because of vacancy. Facility does have a Centrally Stored Medication Record designation in locked closet.

Carbon monoxide and smoke detectors were tested and observed to be operational. No clients’ files reviewed because of vacancy in the facility. No staff files were reviewed as facility does not currently have staff. Licensee and Administrator was advised that staff files will need to be present and ready for review in facility.


No deficiencies issued during this inspection.

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 12/3/24: Lic 308, Lic 500, Lic 610D, Lic 9020 and Administrator Certificate. A copy of this report was provided to Licensee, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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