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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209088
Report Date: 11/08/2021
Date Signed: 11/08/2021 03:37:06 PM

Document Has Been Signed on 11/08/2021 03:37 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:SANCHEZ, CRISTINAFACILITY TYPE:
740
ADDRESS:3425 S. SAN JOAQUIN CT.TELEPHONE:
(559) 799-4086
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 6DATE:
11/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Cristina Sanchez, AdministratorTIME COMPLETED:
01:40 PM
NARRATIVE
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On this date, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced initial complaint investigation and met with Administrator Cristina Sanchez. LPA toured the facility, interviewed clients and staffs.
During the course of the investigation, LPA observed the following deficiencies:

1. Chemicals and knife observed under unlocked resident’s bathroom sink
2. Client sleeping in a room designated for staff per the facility sketch.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Administrator was informed that as a COVID-19 precautionary measure, this report and appeal rights will be provided via email. Report signed on-site
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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Document Has Been Signed on 11/08/2021 03:37 PM - It Cannot Be Edited


Created By: Mai Yang On 11/08/2021 at 12:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DAGO RESIDENTIAL FACILITY #2 ELDERLY
FACILITY NUMBER: 547209088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2021
Section Cited
CCR
80087(g)

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80087(g)Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement was not met:
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Administrator immediately removed chemicals and knife to a secured and locked garage cabinet. POC cleared during inspection.
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Based on observation, LPA observed chemicals and knife unlock under resident's bathroom, this posses an immediately health and safety and personal rights risk to the client.
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Type B
11/14/2021
Section Cited
CCR80022(b)(7)

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A sketch of the building(s) to be occupied, including a floor plan which describes the capacities of the buildings for the uses intended, room dimensions, and a designation of the rooms to be used for nonambulatory clients, if any.
This requirement was not met:
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Administrator states that facility sketch will be updated to reflect correct designated rooms for resident. Updated facility sketch will be submitted to CCL by due date.
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Based on observation and interviews conducted, resident was moved into a bedroom designated for staff which posses a potential health and safety and personal rights risk to the client.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021


LIC809 (FAS) - (06/04)
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