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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206664
Report Date: 11/22/2021
Date Signed: 11/22/2021 04:21:50 PM

Document Has Been Signed on 11/22/2021 04:21 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:BURRUS ADULT RESIDENTIALFACILITY NUMBER:
107206664
ADMINISTRATOR:BURRUS, LINDAFACILITY TYPE:
735
ADDRESS:157 N. ARMSTRONGTELEPHONE:
(559) 321-8737
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Caregivier Ansar Timmons and Licensee Linda Burrus via telephoneTIME COMPLETED:
01:30 PM
NARRATIVE
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On 11/22/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was met by caregiver Ansar. Caregiver called Administrator. Administrator state unable to attend meeting and authorized caregiver to sign and received report. Upon entry staff was observed not wearing facial covering. Visitor log in/temperature check was not observed upon entry.

LPA conduct tour with caregiver. Two clients were present during the tour. Facility has one entrance/exit point. Facility is currently renovating. Social distancing is maintained in the common and dining areas. LPA observed social distancing postings. Food supply was checked and there appeared to be an adequate supply. LPA checked residents’ locked medications. Chemicals are secure and locked under kitchen sink and cabinet in laundry room. LPA observed fire extinguishers with a service date of: 07/20/20. Last fire drill 07/06/21. LPA did not observe a 30-day PPE supplies. Trash bin in bathrooms was observed with no lid. LPA observed hand washing posting by bathroom sinks. LPA toured all bedrooms. All 4 bedrooms are single occupant and observed to be adequately furnished and lit. 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 residents 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. Please submit the following forms/information to Fresno CCL by: 12/3/21. Requested forms/ information: LIC 308, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9020, and LIC 808. Due to COVID-19 precautionary measures, a copy of this report and appeal rights will be provided via email. Report signed on-site

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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 11/22/2021 04:21 PM - It Cannot Be Edited


Created By: Mai Yang On 11/22/2021 at 12:56 PM
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: BURRUS ADULT RESIDENTIAL
FACILITY NUMBER: 107206664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

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
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Based on observation, Fire Extinguisher has a service date of 07/20/2020, which poses an immediate health and safety risk to the residents.
POC Due Date: 11/23/2021
Plan of Correction
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Administrator states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 11/23/21.
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: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


LIC809 (FAS) - (06/04)
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