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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203515
Report Date: 05/28/2021
Date Signed: 05/28/2021 03:43:46 PM

Document Has Been Signed on 05/28/2021 03:43 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:RUBY'S VALLEY CARE HOMEFACILITY NUMBER:
107203515
ADMINISTRATOR:ANTHONY BEASLEYFACILITY TYPE:
735
ADDRESS:9919 SOUTH ELM AVE.TELEPHONE:
(559) 834-6038
CITY:FRESNOSTATE: CAZIP CODE:
93706
CAPACITY: 50CENSUS: 45DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Administrator, Anthony Beasley, Jr. and Administrator, Shinae BishopTIME COMPLETED:
12:30 PM
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On 5/28/2021, Licensing Program Analyst (LPA) A. Walton arrived at the above facility unannounced to conduct an Annual Required Inspection. LPA was greeted and screened by Front Desk staff. LPA introduced self and requested to meet with the Administrator. LPA met with Administrator (A1), Anthony Beasley, Jr. and Administrator (A2), Shinae Bishop. Facility has one central entry point designated for universal entry screening. LPA observed a hand-washing station prior to entering the facility. Facility utilizes a visitor log to screen staff, visitors and residents upon entry to the facility. Screening includes temperature checks and a COVID-19 screening questionnaire.

LPA conducted a facility tour with A1 and A2. During the inspection, the facility was observed to be clean and all exits were open and free of obstructions. Facility staff and residents were observed to be wearing face masks while in the facility. LPA toured the medication room and observed a 30-day supply of medications for residents. Facility tour continued to resident rooms. LPA observed approximately 6-feet between resident beds. Resident bathrooms were stocked with liquid soap and paper towels. LPA observed hand washing posters in resident bathrooms.

Kitchen tour conducted. LPA observed 2-day supply of perishable foods and a 7-day supply of non-perishable foods. The hallways in the facility were equipped with hand sanitizer dispensers and LPA observed signs promoting hand-washing, cough/sneeze etiquette, and physical distancing throughout the facility. Facility has limited capacity in Activity rooms to allow for social distancing. The facility is cleaned and sanitized hourly. Facility has an adequate supply of PPE. PPE and cleaning supplies is audited weekly by the Operations Manager.

CONTINUED TO LIC809-C

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2021
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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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: RUBY'S VALLEY CARE HOME
FACILITY NUMBER: 107203515
VISIT DATE: 05/28/2021
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LPA reviewed a sample of staff and resident files. Staff files observed to have health screening. Resident files observed to have updated/current emergency contact information. Administrator Certificates observed to be current during today’s visit.

No deficiencies issued during today’s inspection.

An exit interview was conducted with A1 and A2. A1 and A2 were informed that as a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
LIC809 (FAS) - (06/04)
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