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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206953
Report Date: 02/01/2022
Date Signed: 02/02/2022 08:48:15 AM

Document Has Been Signed on 02/02/2022 08:48 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:BLUEBERRY HILLFACILITY NUMBER:
107206953
ADMINISTRATOR:CASTIGADOR, YOLANDAFACILITY TYPE:
740
ADDRESS:7447 N RIVERSIDE DRIVETELEPHONE:
(559) 981-5630
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 5DATE:
02/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Yolanda CastigadorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Health & Safety Inspection in conjunction with opening a complaint (24-AS-20220131114428). LPA explained the purpose of the visit with Administrator (AD) Yolanda Castigador.

LPA and AD toured the facility inside and out. 5 residents were observed in their rooms or watching television. Medications were observed in a locked cabinet in the kitchen. Residents rooms were clean and required furnishings and lighting was observed. LPA observed 2 day perishable and 7 day non-perishable food supply. Bathrooms were clean and without odor. Towels, linens, hygiene items and paper products were stored properly. Bathroom water temperature was 113 degrees F. Outside of the facility toured. No bodies of water or other hazards were observed. LPA observed a self-releasing gate and windows have screens in good repair.

LPA removed R1’s file from the facility to make a copy at the CCLD office. The file will be returned to the facility within 3 business days.

See Lic809-D for deficiencies and Plan of Correction




An exit interview was conducted with the Administrator. A copy of this report along with Appeal Rights were provided to Administrator via email at ronald.sandone@yahoo.com

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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 02/02/2022 08:48 AM - It Cannot Be Edited


Created By: Katie Brown On 02/01/2022 at 03:40 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: BLUEBERRY HILL
FACILITY NUMBER: 107206953

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2022
Section Cited
CCR
87307(d)(6)

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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement was not met as evidenced by

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DEFICIENCY CLEARED.

The safety gates were both removed from the walls and disposed of during the inspection.
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Licensee did not ensure that passageways were clear and free of obstruction. A locked gate was placed by the facility on both entry ways into the kitchen.

This poses an immediate health and safety risk to persons in care.
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Type A
02/02/2022
Section Cited
CCR87309(a)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement was not met as evidenced by:
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DEFICIENCY CLEARED
Disinfectants and cleaning supplies were removed and locked in a cabinet in the garage.

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Licensee did not ensure that disinfectants and cleaning supplies inaccessible in the laundry room and kitchen. The magnetic locks under the kitchen sink were broken or not functioning properly.

This poses an immediate health and safety risk to persons in care.
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Licensee has agreed to place a lock on the door knob leading to the laundry room and garage. Magnetic locks to be replaced under the kitchen sink. Pictures of the new door knob with lock and repaired magnetic locks will be provided to CCLD by 2/10/22
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2022


LIC809 (FAS) - (06/04)
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