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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203515
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:42:47 PM

Document Has Been Signed on 05/04/2023 02:42 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
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:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Assistant Administrator, Anthony Beasley, Program Administrator, Shanae Bishop, and Operations Administrator, Allyson DearmondTIME COMPLETED:
02:20 PM
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On 05/04/2023, Licensing Program Analyst (LPA) A. Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self and stated the purpose of the visit and was allowed to enter the facility by . LPA met with Assistant Administrator, Anthony Beasley, Program Administrator, Shanae Bishop, and Operations Administrator, Allyson Dearmond.

LPA conducted a tour of the facility. During the inspection the facility appeared clean and odor free and at a comfortable temperature. Common areas were furnished and had adequate seating and lighting available. LPA toured rooms 16, 13, 12, 10, 1, 4, 7, 8, and 5. Resident bedrooms appeared clean and had required furnishings and adequate lighting. Residents bathrooms appeared clean, water temperature ranged between 116.3 degrees F and 119.9 degrees F. Facility kitchen appeared to be clean and safe for food preparation. LPA observed 2-day supply of perishable foods and a 7-day supply of non-perishable food.

Exterior tour conducted, all exits open and free of obstructions on today’s visit. Fire extinguishers are current with a service date of 04/2023. Smoke detectors and carbon monoxide detectors observed to operational. Last fire drill conducted on 03/17/2023. Cleaning supplies observed to be locked in a closet. LPA reviewed client and staff files. Medications observed to be locked and administered as prescribed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 05/18/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020), Surety Bond.



No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Assistant Administrator, Anthony Beasley Jr., whose signature on this form confirms receipt of this documents
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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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