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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209026
Report Date: 12/13/2021
Date Signed: 12/13/2021 04:44:44 PM

Document Has Been Signed on 12/13/2021 04:44 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:LLC RETIREMENT HOMES IIFACILITY NUMBER:
247209026
ADMINISTRATOR:LAMERSON, LINDSEYFACILITY TYPE:
740
ADDRESS:1944 FAXON DRTELEPHONE:
(209) 761-2478
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 6CENSUS: 6DATE:
12/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Administrator, Norma CejaTIME COMPLETED:
12:58 PM
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On 12/13/2021, Licensing Program Analysts (LPAs) A. Walton and K. Kaur arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced selves stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Administrator, Norma Ceja. Facility has one central entrance and exit. LPAs observed a visitor log/temperature check upon entry.

Facility tour conducted with Administrator. All pathways, entrances and exits were clear from obstructions. LPAs observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. Facility staff observed to be wearing facial coverings. LPAs toured the facility kitchen. LPAs observed a 7-day supply of perishable foods and a 2-day supply of perishable foods. LPAs observed a 30 day supply of PPE and cleaning supplies.

Resident at the above facility have private bedrooms. Bedrooms were stocked with hand sanitizer. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs were not observed in resident bathrooms. LPAs checked residents' medication and observed a 30 day supply. Resident temperature checks are documented daily. Resident records have updated emergency contact information. Facility staff records reviewed for good health and infection control training.

No deficiencies issued during this inspection.

LPAs are requesting the following documents be submitted to the Fresno CCL office by 12/27/2021: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020A

Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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