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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203515
Report Date: 07/05/2022
Date Signed: 07/05/2022 10:14:49 AM


Document Has Been Signed on 07/05/2022 10:14 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: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: 39DATE:
07/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Administrator, Anthony Beasley, Jr.TIME COMPLETED:
10:20 AM
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On 07/05/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Anthony Beasley, Jr.

The purpose of today’s visit is to follow up on an incident report submitted to the Fresno Community Care Licensing (CCL) office on 06/29/2022. It was reported that on 06/28/2022, at approximately 11:01 PM, R1 went AWOL from the facility.

On 06/20/2022, the facility received a citation when another client went AWOL from the facility. The due date for the Plan of Correction (POC) is 07/08/2022.

No additional deficiencies cited during today’s visit. LPA amended the report created on 06/20/2022 to add the following to the POC: proof of training for all staff on personnel requirements and AWOL procedures and a copy of the facility’s AWOL procedures. POC due date will be extended to 07/15/2022

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Anthony Beasley, Jr., whose signature on this form confirms receiving this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
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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