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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 04/29/2025
Date Signed: 04/30/2025 10:00:55 AM

Document Has Been Signed on 04/30/2025 10:00 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 ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ATWATER RESIDENTIAL CARE FACILITYFACILITY NUMBER:
247209209
ADMINISTRATOR/
DIRECTOR:		JOHNSON, JESSICAFACILITY TYPE:
740
ADDRESS:1691 JOE SILVA AVENUETELEPHONE:
(209) 430-1688
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 5CENSUS: 5DATE:
04/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Administrator, Surinder AhluwaliaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sarah Hurt and Vadim Gorbam conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Surinder Ahluwalia, Continual Administrator's Certification expires 01/13/2027. There are currently 5 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector. Water temperature was tested at 113 degrees. First Aid kit is on site and complete.

The facilities Infection Control Plan has not been reviewed annually. The facilities Emergency and Disaster Plan LIC610E has not been reviewed annually. LPA's observed cleaner disinfectant in Resident 1's bathroom, and bleach cleaning products in hallway bathroom accessible to residents. Resident 2's bedroom is missing desk lamp. Staff 1 does not have CPR/First aid training. Staff 2 does not have LIC503 Health Screening Report. LPA's observed back patio furniture without cushions, backyard grass is dry and overgrown. LPA's observed two backyard window screens with holes. Resident 3's medication was not properly logged on the Centrally Stored Medication record. The facility is not using designated bedrooms on original facility sketch as listed (office is being used as a resident bedroom.) The facility does not have proof of required disaster drills.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator, Surinder Ahluwalia, and copy of report left at facility
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Sarah Hurt
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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 04/30/2025 10:00 AM - It Cannot Be Edited


Created By: Sarah Hurt On 04/29/2025 at 12:14 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
,
, CA

FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two of three facility bathrooms had cleaning supplies accessible to residents,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Administrator will train facility staff on safe storage of chemicals and submit to LPA by POC date of 04/30/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/30/2025 10:00 AM - It Cannot Be Edited


Created By: Sarah Hurt On 04/29/2025 at 12:14 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
,
, CA

FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Staff 1 does not have current CPR/First aid training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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Administrator will submit proof of Staff 1's CPR/First aid training and submit to LPA by POC date of 05/15/2025.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Staff 2 does not have required health screening/ TB, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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Administrator will provide proof of Health screening to LPA by POC date of 05/14/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/30/2025 10:00 AM - It Cannot Be Edited


Created By: Sarah Hurt On 04/29/2025 at 12:14 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
,
, CA

FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Record review, the licensee did not comply with the section cited above in Resident 3's medications are not logged up to current date on the Centrally Stored Medication record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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Administrator will conduct medication handling training and submit proof to LPA by POC date of 05/14/2025.
Type B
Section Cited
CCR
87208(a)(7)(a)
87208 Plan of Operation
(7) Sketches, showing dimensions, of the following:
(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility is using bedrooms for purposes other than listed on facility sketch (using office as bedroom) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Administrator will work with Licensing to ensure facility sketch is updated to reflect current bedroom use.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephenie Doub
NAME OF LICENSING PROGRAM MANAGER:
Sarah Hurt
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
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