107201450-1-19-2023-24-AS-MYAG-CN8QSQ-20230119112554

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201450
Report Date: 01/19/2023
Date Signed: 01/19/2023 11:26:19 AM

Document Has Been Signed on 01/19/2023 11:26 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:	CHRISTINA'S CARE HOME		FACILITY NUMBER:	107201450
ADMINISTRATOR:	STEPHEN, RAVI		FACILITY TYPE:	740
ADDRESS:	2551 MESA AVENUE		TELEPHONE:	(559) 347-9900
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 6	DATE:	01/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Care Coordinator Shannon Steele		TIME COMPLETED:	11:40 AM

NARRATIVE

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On 01/19/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced at 09:04 am 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. Ravi Stephen, Administrator was called, stated unable to attend meeting and authorized Care Coordinator (CC) Shannon Steele to receive and sign report. CC arrived shortly and conducted tour with LPA. All six residents were present during the inspection.

Upon entry facility staffs 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 with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed COVID-19 relate signs and cough etiquette posting in facility.

Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage and under kitchen sink. LPA and CC 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. LPA observed 4 bedrooms that are single occupant and 1 shared resident’s bedroom to be at least 6 feet apart.The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health. All residents’ records reviewed to have updated emergency contact information. LPA checked residents’ locked medications and observed 30-day PPE supplies.

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

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 1/25/23. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610E,Lic 808, Lic 9282, current liability insurance, and current Administrator certificate. A copy of this report and appeal rights was provided to Care Coordinator via email. Report signed on site.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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 01/19/2023 11:26 AM - It Cannot Be Edited

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: 01/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA and Care Coordinator observed Fire Extinguisher has a service date of 05/07/21, which poses an immediate health and safety risk to the residents.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 01/20/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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 Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

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