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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208860
Report Date: 01/12/2024
Date Signed: 03/19/2024 10:14:55 AM


Document Has Been Signed on 03/19/2024 10:14 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:A PLUS BOARD AND CARE HOMEFACILITY NUMBER:
107208860
ADMINISTRATOR:TIBURCIO, RAULFACILITY TYPE:
740
ADDRESS:6757 E. CHRISTINE AVENUETELEPHONE:
(559) 493-9141
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 4DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Raul Tiburcio, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with Administrator Raul Tiburcio (AD) and explained the purpose of the visit. Facility was toured with AD.
During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting in 3 of the 4 bedrooms. LPA is requesting an AD submit and exception for furniture not available in R1’s bedroom. LPA observed required items in two resident bathrooms with hot water measuring 109.1 and 116.8 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed required food supply and paper products. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors, gate was found to be in working order. First aid kit located in locked cabinet in kitchen and found to contain required items.
Fire Extinguisher located in the kitchen was serviced on 7/6/2023. Smoke and Carbon Monoxide detectors are tested found to be operational. LPA conducted resident and staff file reviews and interviews. Administrator’s re-certification was confirmed to be in active status.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/19/2024: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Exemption Request Letter, staff training verification.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
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 03/19/2024 10:14 AM - 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: A PLUS BOARD AND CARE HOME
FACILITY NUMBER: 107208860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)(1-5)
87219 (a)(1)(2)(3)(4)(5) Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as …recreation, arts, crafts, music and care of pets. (2) Daily living skills/activities which foster and maintain independent functioning... (4) Physical activities such as games, sports and exercise which develop and maintain strength, coordination and range of motion. (5) Education, achieved through special classes or activities.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with licensee, the licensee did not comply with the section cited which poses/posed a potential health, safety or personal rights risk to persons in care. AD has calendar of planned activities for the month however AD stated he does not offer them on a daily basis.
POC Due Date: 01/19/2024
Plan of Correction
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Licensee will offer activities to residents on a daily basis and will have the supplies necessary to provide the activities.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
LIC809 (FAS) - (06/04)
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