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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209495
Report Date: 11/25/2024
Date Signed: 11/25/2024 01:00:42 PM

Document Has Been Signed on 11/25/2024 01:00 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:AGING GRACEFULLY SENIOR LIVINGFACILITY NUMBER:
107209495
ADMINISTRATOR/
DIRECTOR:		GAYNOR, DONTEFACILITY TYPE:
740
ADDRESS:951 E ALLUVIAL AVE.TELEPHONE:
(559) 570-8763
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 6CENSUS: 4DATE:
11/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:08 AM
MET WITH:Administrator - Donte GaynorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 11/25/2024 at approximately 10:08 AM Licensing Program Analyst (LPA) M Vega arrived to the facility announced to conduct the Pre licensing visit. LPA met with S1 which granted LPA's entry into the facility. LPA shortly met with Administrator Donte Gaynor and Licensee Camalah Kopacz.

LPA toured facility. Common rooms have adequate furnishings and lighting. There are a total of six (6) bedrooms in the residence. Four residents (4) currently in the facility. All of the resident bedrooms have all the required furnishings and adequate lighting. LPA observed a supply of extra bed linens and personal hygiene and grooming products. Kitchen observed to have dishes, plates, utensils. Cleaning supplies are stored in a locking cabinet. Medications are locked in a medication cabinet in Office area. First aid kit contains all the required items. A fire extinguisher is present and has a service date of 05/22/2024. Fire alarm has a complete panel for carbon monoxide that is hard wired throughout residence.

Outside of the facility toured. Exits open free of obstruction, perimeter gate around facility is in place. The residence has a delay egress on doors. No outside hazards were observed. No pools or bodies of water.

All required postings are posted. Facility phone number will be (559) 570-8763.

Component III was conducted during pre-licensing visit with Applicants.

I have found that applicant has met all pre licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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