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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547204137
Report Date: 04/21/2022
Date Signed: 04/21/2022 02:31:50 PM

Document Has Been Signed on 04/21/2022 02:31 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:RUF RICKMAN RESIDENTIALFACILITY NUMBER:
547204137
ADMINISTRATOR:RUF, AMYFACILITY TYPE:
735
ADDRESS:2042 W.ORANGE AVE.TELEPHONE:
(559) 568-0708
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Veronica RickmanTIME COMPLETED:
02:35 PM
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On 4/21/2022, Licensing Program Analyst (LPA) M. Medina conducted an Annual Required Infection Control Inspection. LPA Medina met by Licensee, Veronica Rickman and stated the purpose of the facility visit. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Tour of the facility conducted. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitor. Resident bedrooms toured, resident bedrooms with two occupants have a minimum of 6 feet between beds.

LPA checked residents’ medications and observed a 30-day supply. LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available. Cleaning and PPE supplies were checked. Resident’s files have updated emergency contact information. Fire extinguisher present with a service date of 11/18/2021. LPA observed carbon monoxide detectors and smoke detectors to be operational during today's inspection.

LPA is requesting the following documents be submitted to Fresno CCL office no later than 5/6/2022: Administrator Certificate, CPR/First Aid card, LIC 500, LIC 610 and LIC 9020.

Outside of facility toured. No hazards observed.

No deficiencies were observed during inspection. Exit interview was conducted. Copy of inspection report given to licensee
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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