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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209006
Report Date: 10/25/2024
Date Signed: 10/25/2024 03:33:53 PM

Document Has Been Signed on 10/25/2024 03:33 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:RISING SUN CARE HOME INCFACILITY NUMBER:
107209006
ADMINISTRATOR/
DIRECTOR:		SINGH, PARDEEPFACILITY TYPE:
740
ADDRESS:154 N LIND AVETELEPHONE:
(559) 313-4515
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Marites PaggaoTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 10/25/2024, Licensing Program Analyst (LPA) Daiquiri Boyd arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by caregiver staff, J. Paggao. LPA explained the purpose of the visit and staff M. Paggao stated that the Administrator was out of the country and that she would call the other Administrator to come. M. Paggo stated that Administrator Parminder Kaur was working as a Hospice Nurse and she was unable to come right now, but might come later. LPA called Administrator Kaur and was given permission for M. Paggo to assist LPA today and sign and Administrator Kaur is available by phone.

The residence was set at 75 degrees F temperature and free of passageway obstructions inside and outside. LPAs observed six bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition. Hot water temperature was measured at 120 degrees F. Medications were observed locked in a closet off of the kitchen area.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. Medications are locked next to the kitchen. Sharps and knives are locked in the kitchen area. Cleaning supplies were locked under kitchen sink. Smoke detectors and carbon monoxide were checked and operating. Fire extinguisher was new and purchased on 07/10/2024. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction. Backyard gate connecting to the front driveway does not close without force.

Emergency and Disaster Plan dated 09/20/2019 was observed on the wall of the facility and needs to be reviewed at least annually, which it has not been.

Sergiy PidgirnyTELEPHONE: (559) 243-8080
Daiquiri BoydTELEPHONE: 559-243-8080
DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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 3
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: RISING SUN CARE HOME INC
FACILITY NUMBER: 107209006
VISIT DATE: 10/25/2024
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During the visit a file review was conducted for residents and staff files. See LIC811 for confidential names.

Refer to 809D for deficiencies issued on this day.

An exit interview was conducted, and a copy of this report was provided to caregiver staff, M. Paggao whose signature confirms receipt.



LPA requested the following updated forms faxed to CCLD by 11/01/24: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage, and administrator certificate.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Daiquiri BoydTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2024 03:33 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: RISING SUN CARE HOME INC
FACILITY NUMBER: 107209006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of four residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Caregiver was able to contact Administrator and get a copy of the clients LIC 602. LPA had already completed the inspection so deficiency was issued. LPA will clear this today. No plan of correction is due for this citation.
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one backyard exit gate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Facility shall provide pictures of the gate, once they make necessary repairs. Proof is to be emailed to Licensing by 11/01/2024.
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) -243-8080
LICENSING EVALUATOR NAME: Daiquiri BoydTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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