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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270707264
Report Date: 05/13/2023
Date Signed: 07/07/2023 10:00:05 AM

Document Has Been Signed on 07/07/2023 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:CAUNTAY BOARD & CARE HOME #2FACILITY NUMBER:
270707264
ADMINISTRATOR:GAUDIOSA CAUNTAYFACILITY TYPE:
735
ADDRESS:263 WEST ALVIN DRIVE #A & BTELEPHONE:
(831) 443-9660
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 10CENSUS: 6DATE:
05/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee, Gaudiosa CauntayTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee, Gaudiosa Cauntay Continual Administrator Certificate expired 03/05/2023.. There are currently 6 residents who reside at this home. 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. 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 and performs disaster drills as required. Water temperature was tested at 120 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.
LPA Hurt observed a broken dresser in one of 6 resident bedrooms, one of three living areas is cluttered and not clean. LPA Hurt observed a gate located in facility courtyard leading to outside to be locked. LPA Hurt observed food inside facility refrigerator in containers without dates or labels.

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

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610 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 Licensee, Cauntay Gadiosa and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2023
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 3
Document Has Been Signed on 07/07/2023 10:00 AM - It Cannot Be Edited


Created By: Sarah Hurt On 05/13/2023 at 02:35 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: CAUNTAY BOARD & CARE HOME #2
FACILITY NUMBER: 270707264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 LPA Hurt observed one of six resident bedrooms to have a broken dresser, and living area to be cluttered with paperwork, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2023
Plan of Correction
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Licensee agrees to clean living area and ensure it is free of clutter, and replace broken dresser by 05/27/2023 POC date.
Type B
Section Cited
CCR
80076(a)(1)
Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.


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 LPA Hurt observed several expired food items in pantry, and containers in refrigerator with no label or date which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2023
Plan of Correction
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Licensee agrees to remove all expired foods, and clean fridge of any containers not labeled or dated, and send proof to LPA by POC date of 05/27/2023.
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:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/07/2023 10:00 AM - It Cannot Be Edited


Created By: Sarah Hurt On 05/13/2023 at 02:52 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: CAUNTAY BOARD & CARE HOME #2
FACILITY NUMBER: 270707264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)(2)
80020 Fire Clearance



(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
(1) The request for fire clearance shall be made through and maintained by the licensing agency.
(2) Prior to the use of secured perimeters, an applicant or licensee for an Adult Residential Facility or Group Home shall meet the fire clearance approval requirements of Title 17, Division 2, Chapter 3, Subchapter 4, Article 12, Section 56072(d) and (h).
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 LPA Hurt observed the courtyard gate leading to front lawn to be locked and secured, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2023
Plan of Correction
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Licensee will remove lock and send proof to LPA Hurt by POC date of 05/14/2023
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.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2023


LIC809 (FAS) - (06/04)
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