107201451-11-21-2024-24-AS-JLEL-DB8VBR-20241121151758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201451
Report Date: 11/21/2024
Date Signed: 11/21/2024 03:18:03 PM

Document Has Been Signed on 11/21/2024 03:18 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	CHRISTINA'S CARE HOME II		FACILITY NUMBER:	107201451
ADMINISTRATOR/ DIRECTOR:	STEPHEN, RAVI		FACILITY TYPE:	740
ADDRESS:	1910 INDIANAPOLIS AVENUE		TELEPHONE:	(559) 347-9900
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Administrator: Shannon Steele		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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On 11/21/24 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Jonard Sta Ana. LPA was granted entry. 5 clients were present during inspection. Administrator Shannon Steele (A1) arrived shortly after LPA’s arrival.

LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 40 degrees F. Cleaning chemicals was observed stored and locked under kitchen sink. Fire extinguisher was observed with a service date of: 3/8/24. Fire drill last completed on 9/19/24. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at 106.5 degrees in bathroom 1, 111.6 degrees in bathroom 2, and 112.4 degrees in bathroom 3. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Medications were checked and observed kept locked in medication cart. Clients’ MARS was reviewed.

Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ files reviewed to have been reviewed. Resident (R1) does not have a complete LIC-602 and TB clearance. Samples of staff files were reviewed and observed. All required documents were reviewed and complete.

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

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 12/5/24: Lic 308, Lic 500, Lic 610D, Lic 9020 and a copy of current Administrator certificate. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report.

See Moua	TELEPHONE: (559) 580-4596
Jacques Leffall	TELEPHONE: 559-243-8080
	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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 11/21/2024 03:18 PM - 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CHRISTINA'S CARE HOME II	FACILITY NUMBER: 107201451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in 1 out of 1 resident does not have a completed LIC-602 and TB clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	Licensee agrees to set up a Dr's appointment and have Dr. complete an LIC-602 and TB Clearance.

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.

See Moua	TELEPHONE: (559) 580-4596
Jacques Leffall	TELEPHONE: 559-243-8080
	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

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