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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201450
Report Date: 12/03/2021
Date Signed: 12/17/2021 03:33:58 PM

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:CHRISTINA'S CARE HOMEFACILITY NUMBER:
107201450
ADMINISTRATOR:STEPHEN, RAVIFACILITY TYPE:
740
ADDRESS:2551 MESA AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Ravi Stephen, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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This is an amended report.

On 12/03/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with John Trinos, Caregiver. LPA toured facility with caregiver. Luijean (Jean) Abragan Designated representative and Ravi Stephen Administrator was called and arrived shortly during tour. All six residents were present during the inspection.

Upon entry facility staff was observed with mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility. LPA observed fire extinguisher served date: 05/07/21. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant and 1 shared resident’s bedroom to be at least 6 feet apart. LPA observed in bedroom 5 exit door blocked by dresser with television on top. LPA checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in the garage. The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed. 3 out of 3 staff that were present during inspection did not have current CPR certification. All residents’ records reviewed to have updated emergency contact information.

Deficiencies are being cited on the attached 809Ds in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested to be submitted to Fresno CCL by: 12/9/21. LIC 308, LIC 500, LIC 9020E. LPA received copy of Administrator Certificate during facility inspection. Administrator was informed that as COVID-19 precautionary measure, this report and appeal rights will be provided via email. Report signed on-site.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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 3
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: CHRISTINA'S CARE HOME
FACILITY NUMBER: 107201450
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202 (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
POC Due Date: 12/03/2021
Plan of Correction
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Administrator immediately moved the dresser with television over to the side of the bedroom. POC cleared during visit. Deficiency cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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 HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: CHRISTINA'S CARE HOME
FACILITY NUMBER: 107201450
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

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 when LPA reviewed and observed staff records. LPA observed 3 out of 3 staff that were present during inspection did not have current CPR certification on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2021
Plan of Correction
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Administrator shall submit to CCLD Fresno by the due date, copies of CPR certification for the 3 staff present during inspecation.
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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3