<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209124
Report Date: 04/28/2023
Date Signed: 04/28/2023 01:05:29 PM

Document Has Been Signed on 04/28/2023 01:05 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:GURROLA CARE HOME #6FACILITY NUMBER:
547209124
ADMINISTRATOR:DURAN, ANDREAFACILITY TYPE:
735
ADDRESS:343 S. MIRAGETELEPHONE:
(559) 719-7484
CITY:LINDSAYSTATE: CAZIP CODE:
93247
CAPACITY: 4CENSUS: 4DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH: Licensee, Mary Ellen Gurrola, House Manager, Christina Duran-Reyes, and Administrator, Andrea DuranTIME COMPLETED:
01:19 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/28/2023, Licensing Program Analyst (LPA) A. Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self and stated the purpose of the visit and was allowed to enter the facility by Licensee, Mary Ellen Gurrola, House Manager, Christina Duran-Reyes, and Administrator, Andrea Duran.

There were no residents present during the inspection. LPA conducted a tour of the facility. During the inspection the facility appeared clean and odor free and at a comfortable temperature. Common areas were furnished and had adequate seating and lighting available. Resident bedrooms appeared clean and had required furnishings and adequate lighting. Residents bathrooms appeared clean, water temperature measured at 131.4 degrees F in bathroom 1. Hot water did not reach 105 degrees F in bathroom 2. Facility kitchen appeared to be clean and safe for food preparation. LPA checked the facility food supply.

Exterior tour conducted, all exits open and free of obstructions on today’s visit. Fire extinguisher is current with a service date of 04/21/2023. Smoke detectors and carbon monoxide detector observed to operational. Last fire drill conducted 04/01/2023. Cleaning supplies observed to be locked in a cabinet. LPA reviewed client and staff files. Medications observed to be locked. Medications observed to be administered as prescribed.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

LPA is requesting the following documents be submitted to the Fresno CCL office by 05/12/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020 ) and Surety Bond

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Licensee whose signature confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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 6
Document Has Been Signed on 04/28/2023 01:05 PM - It Cannot Be Edited


Created By: Alexandria Walton On 04/28/2023 at 12:34 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: GURROLA CARE HOME #6
FACILITY NUMBER: 547209124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above 2 out of 2 bathrooms faucets did not deliver hot water that measured between 105 degrees F and 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the steps the facility will take to ensuer the requirements for section 80088 are met to the Fresno CCL office by the POC due date. Licensee also agreed to document water temperature for one week and submit documentation to the Fresno CCL office by 04/05/2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6