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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204055
Report Date: 10/27/2022
Date Signed: 10/27/2022 10:05:01 AM

Document Has Been Signed on 10/27/2022 10:05 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: 6DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:Bridgida Sengsiri, AdministratorTIME COMPLETED:
10:15 AM
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On 10/27/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self and stated the purpose of the visit. LPA was greeted by Bridgida Sengsiri, Administrator and granted entry. Three clients were present during the inspection. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients 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. LPA observed COVID-19 and cough etiquette postings in facility.

LPA checked clients’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 11/16/21. Last fired drill 08/12/22. Chemicals, gardening tools, and cleaning supplies were stored and unlocked in the garage.

All clients’ room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant and one shared client’s bed to be at least 6 feet apart. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. The exterior tour was conducted. Side gate was self-closing and free of debris. Staff records were reviewed for good health and infection control training. All clients’ 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: 11/2/22. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610D and Lic 9282. LPA received copies of current Administrator certificate and control of property during facility inspection. A copy of this report and appeal rights was provided to Administrator.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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 10/27/2022 10:05 AM - It Cannot Be Edited


Created By: Mai Yang On 10/27/2022 at 09:43 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: 10/27/2022

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:

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, when Administrator and LPA observed cleaning supplies, chemical bottles, a shovel and a toolbox full of tools stored in garage unlock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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Administrator change the garage knob to a locked knob during inspection. POC cleared 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: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022


LIC809 (FAS) - (06/04)
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