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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204055
Report Date: 10/01/2021
Date Signed: 11/01/2021 11:42:41 AM

Document Has Been Signed on 11/01/2021 11:42 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:SENGSIRI HOMEFACILITY NUMBER:
107204055
ADMINISTRATOR:SENGSIRI, BRIGIDAFACILITY TYPE:
735
ADDRESS:1142 CARSON AVENUETELEPHONE:
(559) 325-1752
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 5DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Bridgida SengsiriTIME COMPLETED:
10:30 AM
NARRATIVE
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On 10/1/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, LPA was met by Administrator, Bridgida Sengsiri. Four residents were present during the inspection. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

LPA conducted a complete tour with administrator. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Cough etiquette and COVID signs posted throughout facility. Hand washing posters were observed by the bathroom sink. Fire extinguisher observed to be last serviced 10/05/2020.

LPA checked residents’ locked medications and observed a 30-day PPE supplies. LPA observed a 14- day supply of nonperishable food and a 2-day supplies of perishable food which were stored properly. LPA toured resident bedrooms and bathrooms. The resident’s rooms were toured and were observed adequately furnished and lit. LPA observed one shared room, residents bed to be at least 6 feet apart. Observed 4 single occupant rooms. The exterior tour was conducted. Side gate was self-closing and self-latching. Facility staff was observed with mask on. All resident’s 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 was conducted. A plan of correction was developed and reviewed with the administrator. The following forms were requested: Administrator Certificate, LIC 308, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9020. Please submit the above forms/information to Fresno CCL by: 10/08/21. Administrator was informed that as a COVID-19 precautionary measure, this report and appeal rights will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
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 11/01/2021 11:42 AM - It Cannot Be Edited


Created By: Mai Yang On 10/01/2021 at 10:01 AM
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: SENGSIRI HOME
FACILITY NUMBER: 107204055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087(g) Buildings and Grounds Disinfectants, cleaning solutions, poisons , firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, a full opened comet cleaning chemical was found under kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2021
Plan of Correction
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Licensee removed opened comet cleaning chemical from kitchen sink to locked cabinet during visit.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2021


LIC809 (FAS) - (06/04)
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