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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209058
Report Date: 05/21/2026
Date Signed: 05/28/2026 09:09:44 AM

Document Has Been Signed on 05/28/2026 09:09 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:CHRISTINA'S HOME CAREFACILITY NUMBER:
247209058
ADMINISTRATOR/
DIRECTOR:		PELAYO, CHRISTINAFACILITY TYPE:
740
ADDRESS:8397 KIMBERLY WAYTELEPHONE:
(209) 485-6940
CITY:HILMARSTATE: CAZIP CODE:
95324
CAPACITY: 6CENSUS: 6DATE:
05/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:47 PM
MET WITH:Administrator Christina PelayoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 05/21/2026, Licensing Program Analyst (LPA) Vadim Gorban arrived unannounced for an Annual Required Inspection. LPA met with Administrator Christina Pelayo,( certification number 7020350740 and expiration date of 07/12/2027) stated the purpose of the visit and was allowed entry. A tour of the facility was conducted. Facility has one entrance/exit point.

The facility appeared clean with no obstruction or fire clearance issues. Fire extinguisher service date on November 22th, 2025. Last fire drill recorded on 5/01/2025
Hand sanitizer was readily available to residents and visitors. Bathrooms have trash cans with lid. All three resident bedrooms were checked. Also, exterior tour was conducted.

Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Refrigerator temperature was maintained at 39.0-degree F. and freezer was maintained at -0-degree F. Food supply was checked and there appeared to be an adequate supply.

LPA checked residents’ medication records, medications stored in locked cabinet. Cleaning supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed communicating with resident in polite manner. LPA observed residents after lunch in common area.
LPA reviewed staff, resident’s files and facility for required records.

Facility operational phone number 209-664-1378. Deficiency recoded on LIC809-D
Exit interview was conducted, report signed and with appeal rights provided to administrator for facility records.
NAME OF LICENSING PROGRAM MANAGER: Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST: Vadim Gorban
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2026
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 05/28/2026 09:09 AM - It Cannot Be Edited


Created By: Vadim Gorban On 05/21/2026 at 04:09 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: CHRISTINA'S HOME CARE
FACILITY NUMBER: 247209058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and records review, the licensee did not comply with the section cited above in two out of [total three personal records reviewed files missing recent physicians evaluation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
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Administrator will provide POC to LPA by email (updated residents medical assessment) by POC due date
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 regarding missing Disaster Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2026
Plan of Correction
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Administrator will provide POC to LPA by email with completed/ updated Emergency Disaster Plan by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Vadim Gorban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2026


LIC809 (FAS) - (06/04)
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