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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547204082
Report Date: 12/06/2021
Date Signed: 12/06/2021 12:02:28 PM

Document Has Been Signed on 12/06/2021 12:02 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:ABARQUEZ HOMES INC.FACILITY NUMBER:
547204082
ADMINISTRATOR:ANDRES, RICARDOFACILITY TYPE:
735
ADDRESS:312 NW 4TH STREETTELEPHONE:
(559) 741-1296
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Ricardo AndresTIME COMPLETED:
12:00 PM
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Licensing Program Analyst LPA Shawna Doucette and Kamaldeep Kaur conducted an Annual Inspection on this date. LPA was met by Administrator Ricardo Andres and discussed the purpose of the visit. Administrator Ricardo Andres and LPA began the tour at the front entrance of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPAs did not observe a two day supply of perishable food and seven day supply of non-perishable food. Facility had a very small amount of canned foods/snacks for clients in care. Cleaning supplies were observed behind a locked door in the laundry room. LPA observed the following personal protective equipment in a storage cabinet; gown, face shield, gloves, and masks. Staff records were reviewed for infection control training. Administrator advised staff was trained however he does not have documentation. LPA observed all facility staff wearing masks.

Resident’s files have updated emergency contact information.

Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the CCR Title 22. See LIC 809D.


Exit interview was conducted and a copy of this report was provided via email to Administrator.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
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 12/06/2021 12:02 PM - It Cannot Be Edited


Created By: Shawna Doucette On 12/06/2021 at 11:48 AM
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: ABARQUEZ HOMES INC.
FACILITY NUMBER: 547204082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
(d) The licensee shall meet the following food supply and storage requirements:

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in by not having a 7 day supply of nonperishable foods, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2021
Plan of Correction
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Plan of Correction POC Licensee agrees to provide a reciept to show a seven day supply of nonperishable foods and snacks for clients in care by POC due date.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021


LIC809 (FAS) - (06/04)
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