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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209417
Report Date: 09/25/2025
Date Signed: 09/30/2025 09:14:02 AM

Document Has Been Signed on 09/30/2025 09:14 AM - 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: 26DATE:
09/25/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Jessica Pelaya, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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On 09/25/2025, Licensing Program Analysts (LPAs) J. Duarte and L. Salazar arrived at the facility unannounced to conduct a case management visit based on deficiencies found during a complaint investigation.

LPAs conducted a facility tour and and observed R1's room to have five unsecured Oxygen tanks. R1 was observed in a wheelchair. While R1 was moving around the room, the wheelchair wheels were observed to be rolling over the canula tube that measured approximately 20 ft in length, causing possible obstruction to oxygen flow. LPAs conducted interviews with R1 and R2 and observed both residents to not have a signal system to call for assistance.

A review of records reveal, Business Office Manager does not have a criminal background clearance.

Based on observations and records review, and per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809-D. A Civil Penalty in the amount of $500 for Criminal Record Clearance is hereby assessed on LIC421BG. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of persons in care.

An exit interview was conducted with AD and a plan of correction was developed by 09/26/25. A copy of this report and appeal rights were discussed and provided at the time of visit.
NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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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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 09/30/2025 09:25 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/30/2025 09:20 AM


Created By: Jimmy Duarte On 09/25/2025 at 04:19 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: REAL CARE LLC
FACILITY NUMBER: 157209417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/26/2025
Section Cited
CCR
87355(a)

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87355 Criminal Record Clearance
(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.

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Administrator stated that she will contact S1 and advise that until a Criminal Background Clearance is completed and finger prints are completed, S1 is not to return to the facility.
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This requirement was not met as evidenced by LPAs observed S1 to not be on the personnel roster and not finger print cleared. A Civil Penalty in the amount of $500 for Criminal Record Clearance is here by assessed. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of persons in care.
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Deficiency Dismissed
Type A
09/26/2025
Section Cited
CCR87618(b)(3)(E)

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87618 Oxygen Administration - Gas and Liquid
(b) In addition to Section 87611(b), the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This requirement was not met as evidenced by LPAs observation of 5 unsecured Oxygen tanks in Resident R2s room. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of persons in care.
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Administrator stated that oxygen tanks not in use will be removed from the R2's room and the one's in use will be secured. Administrator stated that she will send photos to CCLD and email LPA J. Duarte of the secured oxygen tanks by 09/26/2025.
Deficiency Dismissed
Type A
09/26/2025
Section Cited
CCR
87303(i)(1)(A)

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87303 Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement was not met as evidenced by LPAs observation of Resident R1 and R2 did not have a signal system. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal righs of persons in care.
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Administrator assigned a call pendant to R1 and R2 and stated that all resident will be assigned a pendant by POC due date of 09/26/25.
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: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2025 09:14 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Jimmy Duarte On 09/25/2025 at 04:38 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: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
09/26/2025
Section Cited
CCR
87618(b)(3)(F)

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87618 Oxygen Administration - Gas and Liquid
(b) In addition to Section 87611(b), the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment meets the following requirements:(F)Plastic tubing from the nasal canula or mask to the oxygen source shall be long enough to allow the resident movement within his/her room but does not constitute a hazard to the resident or others.
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Administrator stated that she will contact hospice to order a portable oxygen machine for R1. Administrator will email request to LPA J. Duarte by POC due date of 09/26/25.
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 R1 was observed in a wheelchair. The wheelchair wheels were observed to be rolling over the canula tube while moving around the room. The canula tube was observed to measure approximately 20 ft in length causing possible obstruction to oxygen flow.
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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: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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