107209052-4-23-2025-24-AS-RABE-DFZRPJ-20250423131159

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209052
Report Date: 04/23/2025
Date Signed: 04/23/2025 01:12:22 PM

Document Has Been Signed on 04/23/2025 01:12 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:	CAPOZZI RESIDENTIAL - FILBERT		FACILITY NUMBER:	107209052
ADMINISTRATOR/ DIRECTOR:	CAPOZZI, CHERYL		FACILITY TYPE:	735
ADDRESS:	3059 N FILBERT AVE		TELEPHONE:	(559) 573-7370
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY: 4		CENSUS: 3	DATE:	04/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Jennifer Segura, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) R. Bruce, conducted an unannounced annual visit to the facility and met with Administrator Jennifer Segura (AD). LPA stated the purpose of the visit and was accompanied by AD while conducting the inspection of the facility. Two residents were attending Day Programs and the third was present for the beginning of the inspection and left for an assessment. LPA with AD toured the kitchen. LPA observed that the kitchen was well maintained, with working lights and well maintained appliances. The knives were kept in a locked cabinet in the office. The kitchen counters and sink are free from debris. LPA observed a trash bin with the lid. LPA observed that refrigerator was well maintained and clean. LPA observed a 2 day perishable food supply and 7 days of non-perishable food. No expired food was observed. The kitchen pantry was clean, and organized. LPA observed living room with sofa and love seat. Fireplace with proper screen was observed but is inoperable per AD. Television was observed to be in a secure place, the living room has rug in good condition. The living room can accommodate at least 5 people. The living room has a window that is kept clean and is not obstructed. The furniture was clean and in good condition. LPA observed the dining room is clean, well lit. Dining table can seat 6 people. LPA observed the hallway that leads to the bedrooms, and observed night lights, smoke detectors, and carbon monoxide are installed. A fire extinguisher is mounted on the wall and was last inspected on 11/17/2024. The smoke alarm and carbon monoxide detectors were tested by the AD and are functioning. Closet off the dining room with keypad lock contains detergents, cleaning products and extra supply of soap. LPA toured Laundry room, washer, dryer observed. In upper shelf licensee stores games and activity supplies. Linen closet in hallway stores paper goods (paper towels, toilet paper).

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

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

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)

Page: 2 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: CAPOZZI RESIDENTIAL - FILBERT	FACILITY NUMBER: 107209052
	VISIT DATE: 04/23/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA inspected the hallway bathrooms; there are two. LPA observed the bathrooms are well maintained, well lit, have paper towels, toilet paper, hand soap, and a trash bin with lid. Water temperature measured at 105.2 in first bathroom. LPA observed the linen closet next to the bathroom have clean towels, linens.

LPA observed that the garage is well maintained, free from obstructions, and debris. The garage has storage bins along the walls, refrigerator with freezer contained extra food supply.

LPA inspected the 4 resident bedrooms. Bedrooms are not shared. Each bedroom contained dressers, night stand, closet, TV’s, windows are operable with screens in good condition. Linens and furniture appeared clean and in good condition. Smoke detectors in bedrooms are wired to work together. They were tested and found to be functioning.

LPA with AD inspected the backyard. LPA, observed that the backyard is well maintained, grass in good condition. Patio table and chairs (for 6) are clean and ready for use. The exterior walkways are free from obstructions and debris. Side gate is self-closing and self-latching.

LPA inspected the storage/medication Room. This room is kept locked with key lock accessible only to staff. Resident medications and facility/resident records are stored in this room. AD opened the medication cabinet for inspection. LPA observed medication cabinet contained the first aid kit and medication bins for each resident, labeled and organized. The First aid kit is stored in the medication cabinet and was inspected and found to contain required items.

LPA conducted review of all three resident files and staff records and found that all documents are in order and up to date meeting regulatory requirements.

An exit interview was conducted with AD Jennifer Segura. A printed copy of the report was left with AD.

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3