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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200356
Report Date: 07/28/2025
Date Signed: 07/28/2025 04:41:27 PM

Document Has Been Signed on 07/28/2025 04:41 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:MABUHAY GARDENSFACILITY NUMBER:
107200356
ADMINISTRATOR/
DIRECTOR:		KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:5046 W. SWIFTTELEPHONE:
(559) 400-8573
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 4DATE:
07/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:51 AM
MET WITH:Flora McMurtrieTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Facility Designee (S1) Flora McMurtrie.

During this visit, LPA toured the facility inside & out. Resident rooms and common areas were in good repair and contained the required furnishings and lighting. LPA observed required items in bathrooms which were clean - faucets delivered hot water as required. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper products. Medications are centrally stored in a hallway closet. Cleaning/disinfecting supplies and chemicals are locked and stored in a locked cabinet in the garage. Doors and passageways are unobstructed throughout the facility. First aid kit contained required items.

There is a locked shed in the back yard which stores tools and yard supplies. There are covered seating areas and walkways. Fire extinguishers were found to be charged and serviced 3/19/25 by Jorgensen Fire Co. LPA conducted resident and staff file reviews including medication and centrally stored logs. Infection Control and Emergency/Disaster Plans were reviewed.



Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

See LIC809C for continuation of this report
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Katie Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 17
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/28/2025 04:41 PM - It Cannot Be Edited


Created By: Katie Brown On 07/28/2025 at 02:44 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: MABUHAY GARDENS
FACILITY NUMBER: 107200356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed 4 boxes of Insulin being stored in the drawer of the kitchen refrigerator.
POC Due Date: 07/29/2025
Plan of Correction
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During the visit, staff placed the boxes of Insilin in a locking storage box.
The deficiency is CLEARED DURING INSPECTION
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2025 04:41 PM - It Cannot Be Edited


Created By: Katie Brown On 07/28/2025 at 02:44 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: MABUHAY GARDENS
FACILITY NUMBER: 107200356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(d)(5)
Infection Control Requirements
(d) When an emergency, as defined in Government Code section 8558, or federal emergency for a contagious disease is proclaimed or declared, the licensee shall develop an Emergency Infection Control Plan that includes infection control measures that are not already addressed in the Infection Control Plan as specified in subsection (c), to prevent, contain, and mitigate the associated contagious disease. (5) All staff shall be trained on the Emergency Infection Control Plan immediately but no later than 10 calendar days after submission to the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above inwhich poses/posed a potential health, safety or personal rights risk to persons in care. LPA conducted record review. There was no record of staff S1 or S2 receiving Infection Control Training since the submission of the Infection Control Plan in 2022.
POC Due Date: 08/08/2025
Plan of Correction
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Administrator (AD) has agreed to provide the required Infection Control Training as required. Proof of training will be submitted to CCL by poc date.
Type B
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed an accessible wood plank porch in the back yard with unsecured open areas and which would be a hazard for residents who may walk on the porch.
POC Due Date: 08/07/2025
Plan of Correction
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AD has agreed to secure/repair or remove the wood porch. Pictures of the porch or cleared area will be sent to CCL via email by poc date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2025 04:41 PM - It Cannot Be Edited


Created By: Katie Brown On 07/28/2025 at 02:44 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: MABUHAY GARDENS
FACILITY NUMBER: 107200356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87613(a)(2)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above poses/posed a potential health, safety or personal rights risk to persons in care. R1 is Diabetic and requires some assistance with Glucose monitoring as stated in Physician Report. S1 and S2 assist R1 - there is no documentation of training provided by a licensed professional.
POC Due Date: 08/08/2025
Plan of Correction
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AD has agreed to ensure that S1 and S2, along with any staff that assist R1 with glucose monitoring have received the required training by a licensed professional. Additionally, that this training is documented in the staff files as required. Proof of training will be submitted to CCL by poc date.
Type B
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed moldy bread, spoiled lettuce, cellery, sliced peaches and an open box of hard raisins. Additionally, multiple side drawers required cleaning out due to sticky liquids that had leaked from somewhere.
POC Due Date: 08/08/2025
Plan of Correction
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The spoiled food was thrown away and some food was re sealed. AD has agreed to provide staff training on proper food storage. New storage containers with lids will be provided. Proof of training will be provided to CCL as well as a picture of the new storage containers chosen to be used by poc date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 17
Document Has Been Signed on 07/28/2025 04:41 PM - It Cannot Be Edited


Created By: Katie Brown On 07/28/2025 at 02:44 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: MABUHAY GARDENS
FACILITY NUMBER: 107200356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed Fire and Emergency Drill log - It is not specified if the drills are Emergency or Fire, staff names and shifts conducted are not included on the log.
POC Due Date: 08/08/2025
Plan of Correction
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AD has agreed to revise the Emergency and Fire Drill Logs that will address all required documentation items. A copy of the revised logs will be submitted to CCL by poc date.
Type B
Section Cited
CCR
87611(d)
General Requirements for Allowable Health Conditions
(d) In addition to Section 87463, Reappraisals and Section 8, Observation of the Resident, the licensee shall monitor the ability of the resident to provide self care for the allowable health condition and document any change in that ability.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. R1's Physician's Report is dated 6/12/24 with MCI and Diabetes. R1 is not able to administer own Glucose without assistance from trained staff. S1 stated staff administer the glucuse testing for R1 sometimes because R1 is tired or weak.
POC Due Date: 08/08/2025
Plan of Correction
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AD has agreed to make an appointment for R1 with Physician to be evaluated by PCP and have Physician Report updated as required. A copy of the updated Physician's Report will be submitted to CCL by poc date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2025 04:41 PM - It Cannot Be Edited


Created By: Katie Brown On 07/28/2025 at 03:45 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: MABUHAY GARDENS
FACILITY NUMBER: 107200356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed walls and doors throughout the home that need to be washed (mainly kitchen, common areas), living room blinds to be replaced and the back fence in disrepair, leaning over - being held up with a beam.
POC Due Date: 08/18/2025
Plan of Correction
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AD has agreed to clean the walls, baseboards and internal doors throughout the home. The blinds in the front living room will be replaced. A picture of the kitchen walls and new blinds will be sent. Additionally, a written statement, including dates will be provided for the replacement of the fence in the back yard. These items will be submitted to CCL by poc date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
Page: 16 of 17
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MABUHAY GARDENS
FACILITY NUMBER: 107200356
VISIT DATE: 07/28/2025
NARRATIVE
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An exit interview was conducted and Plans of Correction (POC) were developed. A signed copy of this report and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 8/18/25 - Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coverage, Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402),
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Katie Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
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