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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209048
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:45:01 PM

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:
09/17/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Donna HurleyTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Katie Brown arrived to the facility unannounced to conduct a Health and Safety visit. LPA met with and explained the purpose of the visit with Administrator Donna Hurley.


LPA Katie Brown conducted case management visit for the purpose of observing Resident (R1) after receiving a SOC 341 on 9/8/2021. During this visit, LPA met with R1 and interviewed the Administrator.










No deficiencies were cited on today's visit
Exit interview conducted
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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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