<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167202434
Report Date: 08/30/2024
Date Signed: 08/30/2024 02:08:52 PM

Document Has Been Signed on 08/30/2024 02:08 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:CASA DEL RIOFACILITY NUMBER:
167202434
ADMINISTRATOR/
DIRECTOR:		MARMON, JILLFACILITY TYPE:
735
ADDRESS:817 W SEVENTH STTELEPHONE:
(559) 380-2170
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY: 14CENSUS: 14DATE:
08/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:27 PM
MET WITH: Administrator, Jill Marmon.TIME VISIT/
INSPECTION COMPLETED:
02:21 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
On 08/30/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Jill Marmon..

During the investigation of complaint # 24-AS-20240603123644, LPA found that the facility accepted a client with a diagnosis of dementia without a dementia care plan on file.
A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Jill Marmon, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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 2
Document Has Been Signed on 08/30/2024 02:08 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/30/2024 at 01:32 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: CASA DEL RIO
FACILITY NUMBER: 167202434

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
87208(c)

1
2
3
4
5
6
7
(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation... this requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to review the facility plan of operation and develop a dementia care plan. Licensee will submit an updated plan of operation to the Fresno CCL office by the POC due date.
8
9
10
11
12
13
14
Based on record review, the licensee did not ensure the requirements for section 87208 were met when the facility accepted a client with a diagnosis of dementia without a dementia care plan on file, which posses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
The updated plan of operation shall include a dementia care plan.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2