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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209048
Report Date: 06/06/2023
Date Signed: 07/05/2023 04:45:45 PM


Document Has Been Signed on 07/05/2023 04:45 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:RIVER BLUFFS MEMORY CARE COMMUNITYFACILITY NUMBER:
107209048
ADMINISTRATOR:HURLEY, DONNAFACILITY TYPE:
740
ADDRESS:5425 W. SPRUCE AVE.TELEPHONE:
(559) 840-9347
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:36CENSUS: 35DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Donna HurleyTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Katie Brown and Miriam Flores arrived unannounced to conduct the Annual Inspection. LPAs met with and explained the purpose of the visit with Administrator (AD) Donna Hurley.

During this visit, LPAs toured the facility inside & out. Resident bedrooms contained required furnishings and lighting. LPAs observed hand washing signs and required items in bathrooms. Resident hygiene supplies were properly stored and available. The kitchen observed clean, in good repair with necessary items and appliances. LPAs observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored and locked. First aid kit contained required items. Hot water measured within required range. Facility has designated visitation areas available inside and out. Outside of the facility toured. LPAs observed a self-releasing gate and windows have screens in good repair. Doors and passageways are unobstructed throughout the facility and outside. Fire Extinguishers dated 4/1/23. Smoke and Carbon Monoxide detectors present and in working order. LPA conducted resident and staff file reviews and interviews.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and emailed to Donna Hurley whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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 07/05/2023 04:45 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: RIVER BLUFFS MEMORY CARE COMMUNITY
FACILITY NUMBER: 107209048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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. LPAs observed a razor in the shower of room 2 and Shout laundry spray in the bathroom of room 16. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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Administrator has agreed to provide in-service to staff on proper storage of items that may risk resident safety. A sign in sheet which will include the date, trainer, staff names and signatures will be provided via fax to CCLD by the POC date.
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: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
LIC809 (FAS) - (06/04)
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