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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208772
Report Date: 12/12/2023
Date Signed: 12/12/2023 01:41:41 PM


Document Has Been Signed on 12/12/2023 01:41 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:ROSE MEADOW MANORFACILITY NUMBER:
107208772
ADMINISTRATOR:LEIJA, RITAFACILITY TYPE:
740
ADDRESS:5627 N BOND STREETTELEPHONE:
(559) 840-1991
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 5DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Vanessa CastellanozTIME COMPLETED:
02:00 PM
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On 12/12/23 at 8:10AM, Licensing Program Analyst (LPA) M. Flores arrived unannounced to conduct an Annual inspection. LPA was allowed entry by caregiver staff, Vanessa Castellanoz. Licensee Rita Leija approved for this LPA to complete this annual visit with caregiver, Vanessa Castellanoz.

LPA tour the inside and outside of the facility. The facility was observed to be at a comfortable temperature of 73 degrees F, clean, in good repair, and no passageway obstructions. Cleaning supplies and chemicals are stored and locked under the kitchen sink and in the garage. Sharps are locked and stored in the kitchen area. Medications are kept locked in the hallway closet. All bedrooms were observed to have required furnishings and with adequate lightening. LPA observed three bedrooms. Bathroom is properly equipped, and the hot water temperature was tested at 124.6 degrees F. Carbon monoxide and smoke are dual detectors, they were tested and observed to be operational. A sample of staff and client’s files were reviewed. First Aid checked and fully stocked.

Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

The following updated forms are to be submitted to CCL by 12/26/23: LIC308, LIC 309, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9282, LIC999, and control of property.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with staff. A copy of this report and appeal rights were discussed and left with Caregiver, Vanessa Castellanoz whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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 20


Document Has Been Signed on 12/12/2023 01:41 PM - It Cannot Be Edited

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: ROSE MEADOW MANOR
FACILITY NUMBER: 107208772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)
Medical Assessment
(b) The medical assessment shall include, but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 6 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Licensee agrees to provide the Department copies of medical assessments for R1 and R2 by POC due date.
Type B
Section Cited
CCR
87633(b)(6)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Licensee agrees to provide the Department a training log for the implementation of the hospice care plan for R2 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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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