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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206791
Report Date: 04/12/2024
Date Signed: 04/12/2024 11:29:32 AM

Document Has Been Signed on 04/12/2024 11:29 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:GARIBAY HOME IIFACILITY NUMBER:
107206791
ADMINISTRATOR/
DIRECTOR:		LYDIA GERMAN AKA GARIBAYFACILITY TYPE:
735
ADDRESS:138 E. BELLAIRE WAYTELEPHONE:
(559) 400-6977
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 4CENSUS: 4DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Administrator, Lydia GermanTIME VISIT/
INSPECTION COMPLETED:
11:43 AM
NARRATIVE
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On 04/12/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self and was granted entry to the facility. Facility staff contacted Administrator, Lydia German via telephone. Administrator arrived a short time later. LPA met with Administrator.

LPA conducted a tour of the facility with Administrator. During the inspection the facility appeared clean and odor free and at a comfortable temperature. Common areas were furnished and had adequate seating and lighting available. Resident bedrooms appeared clean and had required furnishings and adequate lighting. Residents bathrooms appeared clean, water temperature measured at 101.6 degrees F. Facility kitchen appeared to be clean and safe for food preparation. LPA observed 2-day supply of perishable foods and a 7-day supply of non-perishable food.

Exterior tour conducted, all exits open and free of obstructions on today’s visit. Fire extinguisher is current with a service date of 09/11/2023. Smoke detectors and carbon monoxide detector observed to operational. Last fire drill conducted on 04/01/2024. Cleaning supplies observed to be locked in a cabinet under the kitchen sink. LPA reviewed client and staff files. Upon review of P&I records, LPA found that resident cash resources are not kept on site and all cash resources are not kept in a bank account. Per Administrator (AD), resident cash resources are withdrawn and are kept at the main office. Medications observed to be locked and administered as prescribed.

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

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Lydia, German, whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/26/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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 04/12/2024 11:29 AM - It Cannot Be Edited


Created By: Alexandria Walton On 04/12/2024 at 10:50 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: GARIBAY HOME II
FACILITY NUMBER: 107206791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(i)
(i) Immediately upon admission of a client, all of his/her cash resources entrusted to the licensee and not kept in the licensed facility shall be deposited in any type of bank, savings and loan, or credit union account… This requirement was not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above cash resources for 4 out of 4 residents were not kept in the facility or bank account and are kept at the main office, which is a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to store cash resources on the facility premises in a locked and secure area or deposit funds in bank account according to section 80026. Licensee will submit written statement, along with proof that cash resources have been stored in the facility or in a bank account, to the Fresno CCL office by the POC due date.
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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2024 11:29 AM - It Cannot Be Edited


Created By: Alexandria Walton On 04/12/2024 at 11:10 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: GARIBAY HOME II
FACILITY NUMBER: 107206791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 hot water measured at 101.6 degrees F., which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee agrees to measure hot water temperature in bathroom 1 and bathroom 3 and document the water temperature on water temperature log. A copy of the water temperature log will be submitted to the Fresno CCL office by the POC due date.
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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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