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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209016
Report Date: 09/29/2022
Date Signed: 09/29/2022 02:09:34 PM

Document Has Been Signed on 09/29/2022 02:09 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: 2DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Davilyn Mancilla, Licensee TIME COMPLETED:
02:30 PM
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On 09/29/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Tereza Molina, Caregiver. Licensee Davilyn Mancilla was called and arrived shortly and conduct tour with LPA. All two residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was not observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. COVID-19 related signs and cough etiquette postings observed. LPA observed fire extinguisher served date: 07/18/22. Facility has COVID Mitigation Plan and Infection Control Plan.

Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information. LPA checked residents’ locked medications.

Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage. LPA observed 30 days PPE supplies. All resident’s room toured and observed to be adequately furnished and lit. LPA observed four single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. The exterior tour was conducted. Side gate was self-closing and self-latching.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 10/5/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Administrator certificate, and current liability insurance. A copy of this report was provided to the Administrator.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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