107206785-4-8-2025-24-AS-RABE-DFK6BG-20250408203954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206785
Report Date: 04/08/2025
Date Signed: 04/08/2025 08:40:15 PM

Document Has Been Signed on 04/08/2025 08:40 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	PETERSON RESIDENTIAL		FACILITY NUMBER:	107206785
ADMINISTRATOR/ DIRECTOR:	O'DONNELL, CAROL		FACILITY TYPE:	740
ADDRESS:	455 S. KONA		TELEPHONE:	(559) 492-2189
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	04/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Carol O'Donell		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts(LPA) Rachel Bruce and Jimmy Duarte arrived unannounced to conduct the Annual inspection. LPAs met with Administrator Carol O'Donnell (AD) and explained the purpose of the visit. Facility was toured with AD. At the time of the visit, LPAs observed that all three residents were present. LPAs toured the facility with AD and observed the following: The Kitchen had working lights and well maintained appliances. The knives were kept in a locked in the laundry room. LPAs observed two trash bins with the lid. LPAs observed that refrigerator was well maintained and clean. LPAs observed a two day perishable food supply and seven day nonperishable supply. The kitchen pantry was clean, organized, and held the facility emergency supply of food. No expired food was observed. LPAs observed the dining room and living room were well lit and free of clutter and/or obstructions. Laundry room is kept locked, along with the washer and dryer there is also a locked cabinet. LPAs observed the storage cabinet to contain laundry detergents and cleaning products. Medications are stored in a separate section of this storage cabinet. First aid kit was observed and contained all required items. LPAs observed that the garage is kept locked and AD explained that residents do not have access to this room. Garage contains upright freezer for food storage. The garage is also utilized to store household chemicals. Although these chemicals were in a cabinet that can be locked away, the lock was not engaged/ AD locked it in LPAs presence. LPAs observed three cats and a cat tree and other cat items in the garage. Litter boxes were maintained and free of any odors. There is a lot of material in the garage, but accessible to access needed items. - Continued to LIC809-C

Sergiy Pidgirny	TELEPHONE: (559) 246-0610
Rachel A Bruce	TELEPHONE: (559) 470-9001
	DATE: 04/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PETERSON RESIDENTIAL	FACILITY NUMBER: 107206785
	VISIT DATE: 04/08/2025

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Continued from LIC 809. Inspection of the living room revealed a Fireplace that was observed with glass cover. The television was observed to be in a secure place, there is also a piano and a bird cage. The living room floor was in good condition. LPAs observed one sofa and two recliners in good condition. The living room has a sliding glass door that is kept clean and is not obstructed.

LPAs observed the hallway that leads to the bedrooms and observed night lights. A fire extinguisher is mounted on the wall in the hallway and one was mounted in the kitchen. Both fire extinguishers were inspected on 12/02/2024. The smoke alarm and carbon monoxide detectors were tested and are functioning appropriately.

LPAs inspected the hallway bathroom with AD and observed that the bathroom is well maintained, well lit, has paper towels, toilet paper, hand soap, and a small trash bin with lid on the counter. Water temperature measured at 110.4 degrees F. The bathroom was observed to have non-skid surface, grab bars in the shower, grip bars around toilet, and a faucet. LPAs observed the linen closet to have adequate supply of clean towels, linens.

Bedrooms were observed to meet regulations and were equipped with a lamp, a chair, a bed, and night stand. Closets provided appropriate storage and windows were operable with a screen in good condition.

LPAs with AD inspected the backyard. LPAs, observed that the backyard is portioned off. Behind a locked gate is a koi pond and turtle pond. Patio table and bench is clean and ready for use. LPAs observed large bird cage with 10-11 birds. LPAs observed a section of the yard fenced off and locked. On the other side of the yard is the side gate which was self-closing and self-latching. However, recent weather caused the wood to swell and AD will address to ensure it remains self-latching. The side walkway that leads to the gate, has three city trash cans that partially obstruct the walkway. AD will address this as well.

LPAs conducted resident and staff file reviews and found both to be in compliance. An exit interview was conducted. A copy of this report was discussed and left with AD whose signature on this form confirms receipt of these documents. Due to printer issues, the report will be emailed.

LPAs are requesting the following documents be submitted to the Fresno CCL office by 04/21/2025. Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), updated facility yard sketch, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), LIC 9052

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Rachel A Bruce	TELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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