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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206669
Report Date: 07/27/2022
Date Signed: 07/27/2022 04:40:49 PM

Document Has Been Signed on 07/27/2022 04:40 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:MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCEFACILITY NUMBER:
107206669
ADMINISTRATOR:MEDINA, MYSTI & ARMANDOFACILITY TYPE:
735
ADDRESS:1354 RAMONA AVE.TELEPHONE:
(559) 292-4183
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 4DATE:
07/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:06 PM
MET WITH:Administrator, Justice MedinaTIME COMPLETED:
04:34 PM
NARRATIVE
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On 7/27/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility unannounced to complete an initial 10-day visit. LPA introduced self and had temperature taken. LPA was permitted entry into facility and met with Administrator, Justice Medina and Mysti Medina. Reason for visit was explained. LPA completed a Health and Safety on residents in care. Residents observed in common areas and in rooms.

During the visit LPA observed the following: No lighting/electricity in hallway off the common area/kitchen to R1's room. LPA observed residents room adjacent to R1's room to the left of the hallway having electricity. Administrator stated that "the electrical has been like this for approximately 2 weeks" and "could not get an electrician out".

Deficiencies cited on LIC 809-D.

Exit interview completed. Appeal rights and a copy of this report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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 07/27/2022 04:40 PM - It Cannot Be Edited


Created By: Mary Garza On 07/27/2022 at 04:14 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: MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCE
FACILITY NUMBER: 107206669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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Administrator to provide a plan of correction in writting to CCL by POC date. Once repairs completed Administrator to provide a copy of repair invoice showing completed.
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This requirement was not met as evidence by: LPA observation of lighting/electricity in hallway off the common area/kitchen to R1's room non-functioning. This poses an immediate health and safety or personal rights violation to residents in care.
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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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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