107209239-12-29-2023-24-AS-KJMC-CYZ2QP-20231229163612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209239
Report Date: 12/27/2023
Date Signed: 12/29/2023 04:36:18 PM

Document Has Been Signed on 12/29/2023 04:36 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:	JAN-ROY PLACE OF FRESNO 2		FACILITY NUMBER:	107209239
ADMINISTRATOR:	HOPPER, JOYCELYN B.		FACILITY TYPE:	740
ADDRESS:	4266 N 9TH STREET		TELEPHONE:	(559) 940-9708
CITY:	FRESNO	STATE: CA	ZIP CODE:	93726
CAPACITY:	6	CENSUS: 5	DATE:	12/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Assistant Administrator (AA) Kirgil Roy Mendoza - by telephone; CareGiver (CG) Augusto Arroyo		TIME COMPLETED:	07:15 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	An unannounced Annual visit was conducted on the date & time indicated above by Licensing Program Analyst (LPA) K. McClurg. LPA met with CareGiver (CG) Augusto Arroyo. LPA introduced self & was allowed entry into facility. CG called Assistant Administrator (AA) Kirgil Roy Mendoza. LPA spoke with AA over phone explaining purpose of visit. AA unable to join LPA facility, therefore CG was verbally authorized to sign for receipt of report. AA was able to join LPA @ facility @ later end of visit. Facility toured. Kitchen observed to be relatively clean, with sufficient amount of plates, glasses, utensils, etc. Refrigerator & Freezer @ appropriate temperatures, & observed to be relatively clean. Garage toured. Freezer in garage @ appropriate temperatures, & observed to be relatively clean. Small refrigerator in garage observed containing medications that were accessible with no lock on appliance, & garage is accessible as door from kitchen to garage is able to be locked/unlocked from inside facility. Small refrigerator with medications moved to locked room @ time of visit. Resident rooms toured. West bedroom @ front of facility had lamp with no lampshade & a chest of drawers was missing a bottom drawer & in further disrepair. Bathroom had grab bars in toilet & shower/tub areas. Outside toured. Lawn mower observed accessible. Mower removed @ time of visit. Interior & exterior passageways observed to be clear with no obstructions. Facilty appeared to be relatively clean with no unpleasant odors. Fire extinguisher service date: 6/19/23. Deficiencies issued. Type A citations (2) were corrected @ time of visit. LPA contacted AA regarding citations & created plans of correction. AA stated that they would join LPA @ the facility shortly. AA arrived @ facility towards end of visit. Exit interview conducted with AA. Report provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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 12/29/2023 04:36 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: JAN-ROY PLACE OF FRESNO 2	FACILITY NUMBER: 107209239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Lawnmover observed in backyard accessible to residents.
	POC Due Date: 12/27/2023
	Plan of Correction
1 2 3 4	DEFICENCY CLEARED @ TIME OF VISIT Lawnmover removed from facility premises @ time of visit.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Medication in closet @ end of interior hallway obsered with unlocked lock mading medications accessible. Small refrigerator in garage containing medications not locked &/or stored where accessible allowing residents to access contents.
	POC Due Date: 12/27/2023
	Plan of Correction
1 2 3 4	DEFICENCY CLEARED @ TIME OF VISIT Medications & appliance containing medications made in accessible.

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: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/29/2023 04:36 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: JAN-ROY PLACE OF FRESNO 2	FACILITY NUMBER: 107209239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Resident west bedroom @ front of house observed to have lamp without shade leaving bulb exposed. Dresser observed to be missing bottom drawer & be in disrepair.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	AA agreed to add lamp shade for lamp & replace dresser with one in good repair. AA to send receipt to LPA for lamp shade & dresser by due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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