107203982-6-13-2022-24-AS-MYAG-CFCQJC-20220613121230

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107203982
Report Date: 06/13/2022
Date Signed: 06/13/2022 12:13:12 PM

Document Has Been Signed on 06/13/2022 12:13 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:	SHINING LIGHT RCFE, THE		FACILITY NUMBER:	107203982
ADMINISTRATOR:	GALVEZ, DELIA		FACILITY TYPE:	740
ADDRESS:	2749 W. SAN CARLOS AVENUE		TELEPHONE:	(559) 449-0410
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY:	6	CENSUS: 5	DATE:	06/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Carlo Santos- Administrator		TIME COMPLETED:	12:20 PM

NARRATIVE

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On 6/13/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced 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 Ralphchris “Ralph” Valencia, Caregiver. Administrator Carlo Santos was called and arrived shortly and conduct tour with LPA. All five residents were present during the inspection.

Upon entry facility staff was observed with facial covering. 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. Social distancing and cough etiquette postings observed.

LPA checked residents’ locked medications. LPA observed small amount of PPE supplies in facility. Food supply was checked and appeared to be an adequate supply. LPA and Administrator observed fire extinguisher served date: 07/22/19.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 1 shared residents’ bed to be at least 6 feet apart and 4 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting not observed by bathroom sinks. 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 resident records reviewed to have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 6/20/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 9020, and control of property. LPA received copy of current liability insurance and administrator certificate. A copy of this report and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

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 06/13/2022 12:13 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SHINING LIGHT RCFE, THE	FACILITY NUMBER: 107203982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Fire Extinguisher has a service date of 07/22/19, which poses an immediate health and safety risk to the residents.
	POC Due Date: 06/14/2022
	Plan of Correction
1 2 3 4	Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 06/14/22.

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.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC809 (FAS) - (06/04)

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