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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209414
Report Date: 05/14/2024
Date Signed: 05/14/2024 09:41:36 AM

Document Has Been Signed on 05/14/2024 09:41 AM - 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:SENIOR CARE COMFORT LIVING #2FACILITY NUMBER:
547209414
ADMINISTRATOR/
DIRECTOR:
PIRA, JOSE JR.FACILITY TYPE:
740
ADDRESS:4043 WEST CLINTON AVETELEPHONE:
(559) 802-3459
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 6CENSUS: 0DATE:
05/14/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Jose Pira, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:03 AM
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ON 05/14/2024, Licensing Program Analyst (LPA) L. Salazar conducted a second Pre-licensing visit. LPA was greeted by Administrator and was granted entry into the facility. LPA conducted the inspection with Administrator using the Inspection Tool. A tour inside and outside the facility was conducted.Comp III was reviewed, and the following regulations were discussed:

Night Supervision: 87415
Persons providing night supervision (10 p.m. to 6 a.m.) for RCFE must be available to assist in caring for residents as required. Staff must be awake for dementia diagnosed residents.

Pre-Admission Appraisal: 87457
Licensee should conduct a pre-appraisal for each resident prior to resident’s admission into the facility.
The appraisal for each resident must be kept on file

Acceptance and Retention limitations:87455
Patients requiring 24hour, skilled nursing or immediate care in a health facility will not be accepted.

Prohibited Health Conditions: 87615
Licensee cannot accept persons who require inpatient care in a health facility or skilled nursing facility or depend on others to perform all activities of daily living.
Licensee cannot accept persons with conditions listed: Stage 3and 4 pressure injuries; gastrostomy tubes; naso-gastic tubes; tracheostomies; staph of other serious infection.

Food Service: 87555
Menus must be written at least one week in advance.
Copies of menus are served as dated and kept on file for 30 days.
Modified Diets as prescribed by a person in care’s physician must be provided to that person in care.

Planned activities: 87219
Licensee must provide planned activities, group interaction, social activities, physical activities.

Record Keeping
LIC 311 C

Administrator will notify licensing and send LIC 9020 (Resident roster) when first resident is accepted. Comp III completed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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