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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206331
Report Date: 09/22/2021
Date Signed: 09/22/2021 11:23:06 AM

Document Has Been Signed on 09/22/2021 11:23 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:RUF ADULT RESIDENTIALFACILITY NUMBER:
547206331
ADMINISTRATOR:RUF, AMYFACILITY TYPE:
735
ADDRESS:940 NORTH BELMONT STREETTELEPHONE:
(559) 784-4657
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 5CENSUS: 4DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Amy RufTIME COMPLETED:
11:28 AM
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Licensing Program Analyst (LPA) M. Medina arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Licensee, Amy Ruf informing her the purpose of the visit. LPA completed the COVID contact questionnaire prior to entrance into the facility.

LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors.

Mitigation plan has been submitted to Department. Infection control procedures described in the plan and observed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), visitation policy, quarantine/isolation procedures, surveillance testing, infection control plan. LPA reviewed Mitigation Plan and procedures with the Licensee.

LPA toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed in the facility. Staff wear face coverings. Facility has designated visitation areas. LPAs observed a 30 day supply of PPE and resident medications. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying were observed.

All residents have private rooms. Food supply adequate for residents in care. Fire extinguisher has a service date of 11/09/2021. Carbon monoxide detector present and observed operational. Facility is equipped with fire door and pull station.

Licensee to submit the following forms to Fresno CCL by 10/01/21: LIC 500, LIC 610, LIC 9020, Administrator certificate, First Aid card.

Through LPA observation, documentation review and interview with Licensee, the required infection control practices are found to be in compliance. No deficiencies cited on today’s inspection.ru
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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