107209006-10-13-2023-24-AS-MFLS-CWKW2R-20231013165447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209006
Report Date: 10/13/2023
Date Signed: 10/13/2023 04:54:53 PM

Document Has Been Signed on 10/13/2023 04:54 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 INC		FACILITY NUMBER:	107209006
ADMINISTRATOR:	SINGH, PARDEEP		FACILITY TYPE:	740
ADDRESS:	154 N LIND AVE		TELEPHONE:	(559) 313-4515
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	6	CENSUS: 6	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Johnmarie Paggao		TIME COMPLETED:	05:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by caregiver staff, J. Paggao and explain the purpose of the visit.

The residence was set at 73 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 109.3 degrees F.

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 extinguishers were charged and was serviced on 7/2/2023. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction.

During the visit a file review was conducted for residents and staff files, refer to 809D for deficiencies.

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

LPA requested the following updated forms faxed to CCLD by 10/20/23: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage, and Plan of Operation, fire drill training, administrator certificate.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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 10/13/2023 04:54 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: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee did not comply with the section cited, 1569.618(c)(3) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit copies of certificates of completion for CPR/First Aid for S1 and S2 by POC due date.

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above, 87608(a)(5)(A) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a copy to the Department of the physician's orders for bed rails for R1 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 Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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