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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206911
Report Date: 06/04/2026
Date Signed: 06/04/2026 05:53:59 PM

Document Has Been Signed on 06/04/2026 05:53 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:CAROLINA HOMEFACILITY NUMBER:
107206911
ADMINISTRATOR/
DIRECTOR:		MISTY BRYSONFACILITY TYPE:
735
ADDRESS:1086 CAROLINA AVENUETELEPHONE:
(559) 326-7758
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 4CENSUS: 4DATE:
06/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator: Misty BrysonTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On 6/4/26 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPAs introduced self, stated the purpose of the visit, and was greet by Staff (S1) Christina Valdez. LPA was granted entry. Program Supervisor (PS) Brandy Woodworth arrived later during inspection. 4 clients were present during inspection after they attended day program.

LPAs toured facility with S1. 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 0 degrees F and refrigerator temperature was maintained at 40 degrees F. Cleaning chemicals was observed stored and locked in cabinet. Fire extinguisher was observed with a service date of: 2/11/26. Fire drill last completed on 5/20/2/26. Clients' 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 range of 109.5 to 109.9 degrees F. in 2 bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Medications were checked and observed kept locked in medication cart. Clients’ MARS was reviewed. Carbon monoxide and smoke detectors were tested and observed to be operational. Samples of staff files and all clients’ files were reviewed and observed to have some missing required documents.

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 6/18/26: Lic 308, Lic 500, Lic 610D, and Lic 9020. LPA received a copy of current Administrator certificate. A copy of this report with Appeal Rights were provided to Program Supervisor, whose signature on this form confirms receipt of

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Jacques Leffall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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)
Page: 2 of 6
Document Has Been Signed on 06/04/2026 05:53 PM - It Cannot Be Edited


Created By: Jacques Leffall On 06/04/2026 at 05:25 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: CAROLINA HOME
FACILITY NUMBER: 107206911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 staff did not contain the LIC-501 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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4
Licensee agrees to complete the LIC-501 and submit documents to CCLD by POC due date.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 staff did not contain the LIC-503 with TB Test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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4
Licesnsee agrees to have staff complete the LIC-503 and TB test and submit completed documents to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/04/2026 05:53 PM - It Cannot Be Edited


Created By: Jacques Leffall On 06/04/2026 at 05:25 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: CAROLINA HOME
FACILITY NUMBER: 107206911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 staff did not contain the LIC-503 with TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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4
Licesnsee agrees to have staff complete the LIC-503 and TB test and submit completed documents to CCLD by POC due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

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 5 residents did not contain an Admission Agreement in resident's file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Licensee agrees to have the Admission Agreement complete and submit to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/04/2026 05:53 PM - It Cannot Be Edited


Created By: Jacques Leffall On 06/04/2026 at 05:25 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: CAROLINA HOME
FACILITY NUMBER: 107206911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 5 residents did not conain the LIC-602 with TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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2
3
4
Licensee agrees to complete the LIC-602 with TB test and submit to CCLD by POC due date.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 5 residents did not conain the LIC-602 with TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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2
3
4
Licensee agrees to complete the LIC-602 with TB test and submit to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/04/2026 05:53 PM - It Cannot Be Edited


Created By: Jacques Leffall On 06/04/2026 at 05:25 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: CAROLINA HOME
FACILITY NUMBER: 107206911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 5 Residents did not contain the LIC-601 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
1
2
3
4
Licensee agrees to complete the LIC-601 and submit to CCLD by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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