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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203515
Report Date: 04/05/2023
Date Signed: 04/05/2023 10:47:57 AM

Document Has Been Signed on 04/05/2023 10:47 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:RUBY'S VALLEY CARE HOMEFACILITY NUMBER:
107203515
ADMINISTRATOR:ANTHONY BEASLEYFACILITY TYPE:
735
ADDRESS:9919 SOUTH ELM AVE.TELEPHONE:
(559) 834-6038
CITY:FRESNOSTATE: CAZIP CODE:
93706
CAPACITY: 50CENSUS: 43DATE:
04/05/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Medical Assistant, Ashley PhillipsTIME COMPLETED:
11:00 AM
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On 04/05/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management - health checks inspection. LPA contacted Administrator via telephone, introduced self and stated the purpose of the visit. Administrator has a prior obligation and will not be able to attend this inspection. LPA received verbal permission to meet with facility staff. LPA met with Medical Assistant, Ashley Phillips.

Residents at the above facility have been temporarily relocated due to the facility being treated for pests. Facility has relocated to a hotel. Residents observed to be in rooms watching TV and outside for break. Staff are sectioned in zones to monitor residents. There one to two residents per room. Food service is delivered to residents and provided by a catering company. Facility has a room designated as a supply room which includes PPE, additional linens, and hygiene products. Facility has also designated a room to administer medications. Medication locked and inaccessible to residents in care. Facility plans to relocate back to the above facility between 4/17/2023 - 4/19/2023.

No deficiencies issued.

Exit interview was conducted. A copy of this report was discussed and provided to Medical Assistant, Ashley Phillips, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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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