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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206953
Report Date: 06/29/2022
Date Signed: 06/30/2022 10:47:03 AM

Document Has Been Signed on 06/30/2022 10:47 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:
06/29/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Yolanda CastigadorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced and conducted Case Management visit. LPA met with and explained the purpose of the Case Management with Administrator (AD) Yolanda Castigador.

During the visit, LPA reviewed R1 resident file and interviewed AD. Record review revealed that the resident file is incomplete.

The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care.









A copy of this report including Plan of Correction and Appeal Rights were provided via email to ronald.sandone@yahoo.com. An exit interview was conducted with AD.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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 2
Document Has Been Signed on 06/30/2022 10:47 AM - It Cannot Be Edited


Created By: Katie Brown On 06/29/2022 at 02:42 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: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2022
Section Cited
CCR
87506(a)

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87506 Resident Records
(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement was not met as evidenced by:
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Administrator (AD) has agreed to conduct an audit of the current 5 resident's files using LIC311 as a checklist. A checklist will be created and completed for each resident currently in care and for future resident admissions.

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Licensee did not ensure the complete and current record for R1.


This poses a potential health & Safety risk to persons in care
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AD agrees to submit a copy of the checklist for each resident currently in care to CCLD by 7/13/22 via email.

A copy of LIC311 was provided.

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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


LIC809 (FAS) - (06/04)
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