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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201564
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:08:02 PM


Document Has Been Signed on 05/06/2022 01:08 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:LOVING CARE ASSISTED LIVINGFACILITY NUMBER:
547201564
ADMINISTRATOR:PERRY, FEFACILITY TYPE:
740
ADDRESS:1542 E. GLENWOOD AVENUETELEPHONE:
(559) 688-4835
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:6CENSUS: 5DATE:
05/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Licensee Ronald PerryTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) L. Cabrera conducted an unannounced Case Management – Deficiencies Inspection on this date. LPA met with Ronald Perry, Licensee and Fe Perry, Administrator.

During the annual inspection on 04/28/2022, per CCL it indicated Staff (S1) fingerprint status was pending. LPA instructed Administrator and Licensee to remove staff from schedule until she obtained further information regarding the status. Per Guardian Background Check System, S1 is not cleared to work at the facility.

Civil penalty was assessed.

Deficiencies are cited on the attached LIC809-D. Exit interview was conducted with the administrator. Appeal rights provided.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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Document Has Been Signed on 05/06/2022 01:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: LOVING CARE ASSISTED LIVING
FACILITY NUMBER: 547201564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2022
Section Cited

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87355 Criminal Record Clearance
(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...(1)Obtain a California clearance or a criminal record exemption as required by the Department
This requirement is not met as evidenced by:
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Staff (S1) is not fingerprint cleared. S1 has been working in the facility since January 2022. This poses an immediate health, safety, and personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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