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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209386
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:12:53 PM

Document Has Been Signed on 10/28/2024 03:12 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:RADIANCE SENIOR CAREHOMEFACILITY NUMBER:
107209386
ADMINISTRATOR/
DIRECTOR:		BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:707 W CHENNAULT AVE.TELEPHONE:
(559) 704-6796
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 5DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator: Elisa PuaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 10/28/24 at 11:30am Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection LPA was greeted by Staff Renaldo Yabut (S1). LPA introduced self, stated the purpose of the visit and Administrator (A1) Elisa Pua was present during inspection. LPA was granted entry. 5 residents were present during inspection.

LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -10 degrees F and refrigerator temperature was maintained at 44 degrees F. Fire extinguisher was observed with a purchase date of: 5/16/24. Fire drill last completed on 10/13/24. Washer and dryer observed operational during visit. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature of 112.6 degrees in bathroom 1 and 110 degrees F. in bathroom 2. Non-skid mat and grab bars observed in bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. A sample of medications were checked and observed kept locked in the hall closet. Residents’ MARS was reviewed. Based on record review LPA observed 1 out of 1 residents medication count was under the required amount. First aide kit observed with all of the required items.

All residents and samples of staff files reviewed to have all the required documents.



Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22,Division 6.

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 11/12/24: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report and appeal rights were provided to Administrator, whose signature on this form confirms receipt of these reports.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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 10/28/2024 03:12 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/28/2024 at 02:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: RADIANCE SENIOR CAREHOME
FACILITY NUMBER: 107209386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 medication R1's medication count was under the required amount which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Administrator agrees to submit in-service medication training completion forms to CCLD
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:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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