107201451-12-3-2021-24-AS-MYAG-C9CUMP-20211203144239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201451
Report Date: 12/03/2021
Date Signed: 12/03/2021 02:42:56 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 HOME II		FACILITY NUMBER:	107201451
ADMINISTRATOR:	STEPHEN, RAVI		FACILITY TYPE:	740
ADDRESS:	1910 INDIANAPOLIS AVENUE		TELEPHONE:	(559) 347-9900
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 6	DATE:	12/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Ravi Stephen, Administrator		TIME COMPLETED:	11:00 AM

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On 12/03/2021, 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 Regaldo (Reggie) Chua, Caregiver. LPA toured facility with caregiver. 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 no 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 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 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 cabinet in the garage.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 12/9/21. The following updated forms were requested: Lic 308, Lic 500, Lic 9020E. LPA received copy of Administrator Certificate and First Aid card during facility inspection.

Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 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)

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