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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209417
Report Date: 09/11/2025
Date Signed: 09/11/2025 01:53:12 PM

Document Has Been Signed on 09/11/2025 01:53 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:REAL CARE LLCFACILITY NUMBER:
157209417
ADMINISTRATOR/
DIRECTOR:		PELAYA, JESSICAFACILITY TYPE:
740
ADDRESS:818 REAL RDTELEPHONE:
(661) 760-7610
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 300CENSUS: 23DATE:
09/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Jessica PelayaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 09/11/2025, LPA J. Duarte and S. Doucette arrived at the facility unannounced to conduct a compliant investigation. During the course of the investigation, LPAs observed deficiencies. LPAs met with Administrator (AD) Jessica Pelaya.

LPAs reviewed resident records including: Centrally Stored Medication, MARS, medication in Memory Care for R1 and R2, hospice records, admission agreements, and physician reports.

During the course of the investigation, LPAs observed the Centrally stored medication log for R1 has a start date of 09/01/2025; however, medication bubble pack has a label indicating Date Opened is 09/05/25. Medication bubble pack shows eight pills out of 28 were administered for the evening and the bubble pack for the morning shows seven out of 28 were administered for the morning. In addition, a medication that indicates to be administered at Noon by pharmacy was crossed out and above was hand written "2 PM."

Facility was unable to provide a centrally stored medication log for R1 and R2 for the month of August of 2025. Facility was unable to provide hospice records for review for R2.

During the tour of the facility, LPAs observed latch locks on the outside of the main building, on top of the door, preventing residents from exiting the facility. LPA took photos.

An exit interview was conducted and a copy of this report was provided with plan of correction and appeal rights. Civil penalty was issued for fire clearance.
NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
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 5
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)
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Document Has Been Signed on 09/11/2025 01:53 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Jimmy Duarte On 09/11/2025 at 10:50 AM
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: REAL CARE LLC
FACILITY NUMBER: 157209417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
09/12/2025
Section Cited
CCR
87465(h)(4)

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87465(h)- The following requirements shall apply to medications which are centrally stored:(4) -All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

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Licensee agrees to submit an agenda and date training will be conducted by the pharmacy to LPA by POC due date (09/12/25).
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This requirement was not met as evidenced by: Licensee did not ensure prescription labels remained unaltered. LPAs observed the time for R1 to take a prescribed medication at noon was altered to indicate to take at 2 PM, which poses an immediate health, safety, and/or personal rights risk to resident in care.
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Request Denied
Type A
09/11/2025
Section Cited
CCR87202(a)

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87202(a) - (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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Licensee agrees to immediately remove outisde latch locks. POC was cleared during the visit. A Civil Penalty was issued.
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This requirement was not met as evidenced by: Licensee did not ensure approved fire cleareance was maintained by attaching latch locks on the outside of the main builiding, on top of the door, locking residents in facility which poses an immediate health, safety, and/or personal rights risk to resident in care.
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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.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/11/2025 01:53 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Jimmy Duarte On 09/11/2025 at 12:40 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: REAL CARE LLC
FACILITY NUMBER: 157209417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
09/12/2025
Section Cited
CCR
87465(a)(4)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.
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Licensee agrees to submit an agenda and training date for admininstering medication to LPA by POC due date of 09/12/25.
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This requirement was not met as evidenced by: Licensee did not ensure R1's medication were issued as prescribed. LPAs observed the Centrally stored medication log for R1 has a start date of 09/01/2025; however, medication bubble pack has a label indicating Date Opened is 09/05/25. Medication bubble pack shows eight pills out of 28 were administered for the evening and the bubble pack for the morning shows seven out of 28 were administered for the morning,which poses an immediate health, safety, and/or personal rights risk to resident in care.
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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.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/11/2025 01:53 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 09/11/2025 at 12:54 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: REAL CARE LLC
FACILITY NUMBER: 157209417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/25/2025
Section Cited
CCR
87465(a)(6)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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Licensee agrees to conduct a training on centrally stored logs by POC due date of 09/25/2025.
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This requirement was not met as evidenced by: Licensee did not ensure R1 and R2 had a centrally stored log for August of 2025, which poses a potential health, safety, and/or personal rights risk to residents in care.
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Request Denied
Type B
09/25/2025
Section Cited
CCR87633(a)(4)

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(a)The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).
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Licensee agrees to submit a Hospice Care Plan for a resident that meets regulations to LPA by POC due date of 09/25/25.
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This requirement was not met as evidenced by: Licensee did not ensure R2 had a Hospice Care Plan, which poses a potential health, safety, and/or personal rights risk to residents in care.
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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.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


LIC809 (FAS) - (06/04)
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