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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400544
Report Date: 09/17/2021
Date Signed: 09/20/2021 10:58:45 AM

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:TERRACES AT SAN JOAQUIN GARDENS, THEFACILITY NUMBER:
100400544
ADMINISTRATOR:SHAUN RUSHFORTHFACILITY TYPE:
741
ADDRESS:5555 NORTH FRESNO STREETTELEPHONE:
(559) 439-4770
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:652CENSUS: 360DATE:
09/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shaun Rushforth, AdministratorTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced case management visit to the facility.

The purpose of the case management visit is to respond an incident report that was submitted to CCL Office and was dated 09/04/2021.

LPA met with Administrator Shaun Rushforth and stated the purpose of the visit. LPA interviewed Administrator regarding Resident (R1) was found on the bedroom floor with her head caught under her bed frame. R1’s spouse got up and did not see R1 and pushed the pendant. Administrator reported R1 is doing well. It was reported that R1 “appeared to roll of the bed at that time of the incident.” Administrator stated R1’s cognitive impairment has declined, and a reassessment was completed. Administrator provided R1’s reassessment and updated care plan.

No deficiencies were observed. Exit interview conducted and Administrator was provided with a copy of this report.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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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