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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208934
Report Date: 03/02/2026
Date Signed: 03/02/2026 11:34:00 AM

Document Has Been Signed on 03/02/2026 11:34 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:RIVENDELL COMMUNITY INCFACILITY NUMBER:
107208934
ADMINISTRATOR/
DIRECTOR:		LY-YANG, XIAMYFACILITY TYPE:
775
ADDRESS:4927 E MCKINLEY AVETELEPHONE:
(559) 458-1958
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 100CENSUS: 55DATE:
03/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator - Xiamy Ly-YangTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 0/02/2026, Licensing Program Analyst (LPA) M Vega arrived unannounced to conduct the Required Annual Inspection. LPA was greeted and allowed entrance by Program Manager Tou Vue, Administrator - Xiamy Ly-Yang arrived a short time later. LPA explained the purpose of the visit and was granted a tour with program manager.

During this visit, program participants were observed engaged in group activities. During the facility tour, LPA observed required items in client restrooms. Restrooms were clean and toilets and sinks operational. Water temperature was 110.4 F in the men’s bathroom. Facility temperature was a comfortable 68 degrees F.

The day program grounds are clean and in good repair. No obstructions and exit doors and passageways are kept clear. There is one big room which serves as the area for clients to participate in activities, eat, and visit. There is a refrigerator available to store the client's food which is brought in. Clients bring their own snacks and lunch room. There is no food preparation conducted on the premises. There are snacks and beverages supplied by the facility. This program does not have an outdoor social area, and so uses the parking lot when whether permits.

Disinfectants and cleaning supplies were locked and inaccessible to clients. Fire Extinguishers are appropriately maintained and located throughout the facility, Date inspected 06/13/2025. Fire Alarm system is inspected annually by Matson Alarm. Emergency drills are conducted quarterly, last drill was conducted in 11/08/2025. Emergency Disaster Plan was reviewed and up to date.

Continuation on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Martin Vega
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2026
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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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)
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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: RIVENDELL COMMUNITY INC
FACILITY NUMBER: 107208934
VISIT DATE: 03/02/2026
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LPA conducted client file reviews and staff file reviews. All were up to date and had required documentation.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Day Program (ADP):

LIC 308 Designation of Facility Responsibility

LIC 309 Administrative Organization

LIC 400 Affidavit Regarding Client/Resident Cash Resources

LIC 500 Personnel Report

LIC 610D Emergency Disaster Plan For Adult Day Program

LIC 9020 Register of Facility Clients/Residents

Copy of current Liability Insurance

Copy of current Administrator Certificate

Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 03/16/2026 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

No deficiencies issued during this inspection. An exit interview was conducted with the AD

A copy of this report was given to AD whose signature on this form confirms receipt of these reports.

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Martin Vega
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
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