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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209016
Report Date: 10/06/2021
Date Signed: 10/06/2021 09:45:17 PM

Document Has Been Signed on 10/06/2021 09:45 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:LOURDES SENIOR CARE HOMEFACILITY NUMBER:
547209016
ADMINISTRATOR:MANCILLA, DAVILYN T.FACILITY TYPE:
740
ADDRESS:2234 EAST KAWEAH CTTELEPHONE:
(559) 802-3319
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 6CENSUS: 4DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:30 PM
MET WITH:Licensee Davilyn Mancilla;TIME COMPLETED:
09:45 PM
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An Annual Inspection Control visit was conducted on the date & times indicated above by LPA K. Mcclurg. LPA met with Licensee (L) Davilyn Mancilla. LPA reviewed the purpose of the visit with L.

Facility tour conducted. One central entry point has been designated for universal entry screening. Routine symptom screening including temperature taken & recorded daily for all staff, residents, & visitors.
Infection Control signs observed to be posted, including in bathrooms with hand washing techniques. Soap & paper towels available. Hand sanitizer available on entry & throughout the facility. Face coverings in use. Infection control policies & procedures & practices in place & currently applied.

No deficiencies issued.
Exit interview conducted with L. Report Provided

Continued.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: LOURDES SENIOR CARE HOME
FACILITY NUMBER: 547209016
VISIT DATE: 10/06/2021
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Continued from Page 1.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents (please include Date of Birth & Admission Date)
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.
Please submit the above forms/information to Fresno CCL by: Sunday, October 31, 2021

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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