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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167202434
Report Date: 08/09/2022
Date Signed: 08/09/2022 11:51:18 AM

Document Has Been Signed on 08/09/2022 11:51 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CASA DEL RIOFACILITY NUMBER:
167202434
ADMINISTRATOR:MARMON, JILLFACILITY TYPE:
735
ADDRESS:817 W SEVENTH STTELEPHONE:
(559) 380-2170
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY: 14CENSUS: 14DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Administrator Jill MarmonTIME COMPLETED:
12:00 PM
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On 8/9/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was allowed entry by Administrator Jill Marmon and House Manager Johnny Bursiaga.

Facility staff were observed with face coverings. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Social distancing and cough etiquette postings observed in facility. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Fire extinguisher in Kitchen was last serviced on 12/15/2021 and was fully charged. A 2-day supply of perishable and 7-day supply of non-perishable food was observed. Cleaning supplies were observed behind a locked door in the kitchen. All resident’s room toured and observed to be adequately furnished and lit throughout. LPA toured bathrooms and observed Trash bins with lids and hand washing signs. LPA checked residents’ locked medication and observed a 30-Day supply kept locked in the office. 30-day supply of PPE and incontinence supplies kept in office.

A small sample of Staff records were reviewed for good health and infection control training. Residents’ records reviewed to have updated emergency contact information. No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 8/16/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization
(LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan
(LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy
provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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