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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209088
Report Date: 09/30/2021
Date Signed: 10/04/2021 12:18:01 PM

Document Has Been Signed on 10/04/2021 12:18 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:DAGO RESIDENTIAL FACILITY #2 ELDERLYFACILITY NUMBER:
547209088
ADMINISTRATOR:DAGO, NORMA & LOPEZ, TAIMIFACILITY TYPE:
740
ADDRESS:3425 S. SAN JOAQUIN CT.TELEPHONE:
(559) 799-4086
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 6DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Cristina Sanchez TIME COMPLETED:
11:45 AM
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On 09/03/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, LPA was met by Direct Support Personnel (DSP) Veronica Noriega, and requested to meet with the Administrator. Administrator, Cristina Sanchez was called and arrived later. Four residents were present during the inspection. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

LPA conducted a complete tour of the facility with DSP and administrator. The facility was observed without any fire clearance issues or obstruction. Cough etiquette and COVID signs posted throughout facility. Common areas had furniture and was lit. LPA observed a hospital bed for one resident in the common area. LPA discussed with administrator regarding a physician order for the bed and relocating to the resident's room.

LPA checked residents’ locked medications and observed a 30-day PPE supplies. LPA observed a 14- day supply of nonperishable food and a 2-day supplies of perishable food which were stored properly. Fire extinguisher observed to be last serviced 12/04/2020. The resident’s rooms were toured and were observed adequately furnished and lit. LPA toured resident bedrooms and bathrooms. LPA observe hand washing sign at all sinks. Cleaning supplies and chemicals were observed in the locked cabinet in the garage. The exterior tour was conducted. Side gate was self-closing and self-latching.

Facility staff was observed with mask on. A sample of residents’ records reviewed to have updated emergency contact information.

LPA, M. Yang follow-up on a case management on incident report that was received on 09/20/21. LPA interviewed staff regarding incident report. No follow-up needed.

No deficiencies issued during this inspection.

Exit Interview conducted. The following forms were requested: Administrator Certificate, updated Liability Insurance, LIC 308, LIC 309 LIC 400, and LIC 402, LIC 500, LIC 610D, LIC 9020. Please submit the above forms/information to Fresno CCL by: 10/07/21.Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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