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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202403
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:47:58 PM

Document Has Been Signed on 03/19/2025 03:47 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:GRAYSFUL LIVINGFACILITY NUMBER:
107202403
ADMINISTRATOR/
DIRECTOR:		FLAUTA, VICTOR S.FACILITY TYPE:
740
ADDRESS:1552 E. MUNCIE AVETELEPHONE:
(559) 297-0233
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Staff 1 - Mark CaluagTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 03/19/2025, Licensing Program Analyst (LPA) M Vega arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured the facility with staff Mark Caluag. Administrator (AD) Jill Stowell was notified of Licensing visit over the phone.

The facility was observed to be at a comfortable temperature, of 73 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed some residents in common area during breakfast watching television, others in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility.

Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

A fire extinguisher was observed with a service date of 05/23/2024. All residents’ bedrooms were observed to be at comfortable temperatures.

Medications observed to be locked in a cabinet in kitchen/dining area. LPA reviewed medication records, at the time of inspection records are accurate. Cleaning supplies were observed to be in a locked cabinet in the storage it the laundry room. An outdoor seating area was observed operational for residents in care.

Continuation on LIC 809C

Brenda ChanTELEPHONE: (650) 272-4781
Martin VegaTELEPHONE: 559-243-8080
DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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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: GRAYSFUL LIVING
FACILITY NUMBER: 107202403
VISIT DATE: 03/19/2025
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Citations issued per the California Code of Regulations Title 22.

Exit interview was conducted and a copy of this report LIC 809, LIC 809D, and appeal rights was/were provided to Staff 1 Mark Caluag.

Administrator Jill Stowell granted via phone permission to Staff 1 Mark Caluag to sign LIC 809 and LIC 809D

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/19/2025 03:47 PM - It Cannot Be Edited


Created By: Martin Vega On 03/19/2025 at 03:23 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: GRAYSFUL LIVING
FACILITY NUMBER: 107202403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of fire clerance and record review (602A), the licensee did not comply with the section cited above in 1 out of 6 residents being bedridden, and fire clearance does not allow for bed ridden residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Administrator will contact Firedepartment Within 24 hours to obtain fire clerance for bedridden resident.
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:Brenda Chan
TELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME:Martin Vega
TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
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