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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206664
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:18:57 PM

Document Has Been Signed on 10/29/2024 12:18 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BURRUS ADULT RESIDENTIALFACILITY NUMBER:
107206664
ADMINISTRATOR/
DIRECTOR:		BURRUS, LINDAFACILITY TYPE:
735
ADDRESS:157 N. ARMSTRONGTELEPHONE:
(559) 321-8737
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator: Linda BurrusTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 10/29/24 at 8:30am Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection LPA was greeted by Ansar Timmons (S1). LPA introduced self, stated the purpose of the visit Licensee (L1) Linda Burrus was present during inspection. LPA was granted entry. No residents were present during inspection because of attendance at day program.

LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -5 degrees F and refrigerator temperature was maintained at 35 degrees F. Fire extinguisher was observed with a purchase date of: 12/5/23. Fire drill last completed on 10/15/24. Washer and dryer observed operational during visit. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature of 116 degrees in bathroom 1 and 110 degrees F. in bathroom 2. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. A sample of medications were checked and observed kept locked in the locked cabinet. Residents’ MARS was reviewed. A sample of medications were checked and observed kept locked in cabinet. First aide kit observed with all of the required items.

All residents and samples of staff files reviewed to have most required documents. Upon review (S1) does not have LIC-503 on file. Upon further review LIC-602 not obtained for 1 out of 1 resident (R1)



Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22,Division 6.

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 11/13/24: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report and Appeal Rights were provided to Licensee, whose signature on this form confirms receipt of these reports.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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 10/29/2024 12:18 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/29/2024 at 11:42 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: BURRUS ADULT RESIDENTIAL
FACILITY NUMBER: 107206664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 Medical Assessment for 1 out of 1 resident's missing medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee agrees to obtain a complete Physician's report at next Dr's appointment for resident.
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:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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