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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200719
Report Date: 08/25/2022
Date Signed: 08/30/2022 08:28:55 AM

Document Has Been Signed on 08/30/2022 08:28 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:VALLEY CHRISTIAN HOME IIFACILITY NUMBER:
107200719
ADMINISTRATOR:GAMUEDA, HONORAFACILITY TYPE:
740
ADDRESS:504 W. MESATELEPHONE:
(559) 438-1009
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 6DATE:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Honora Gamueda, Licensee/AdministratorTIME COMPLETED:
11:15 AM
NARRATIVE
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On 8/25/22 at 8:55 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. LPA met with Licensee Honora Gamueda. One staff and five residents were present during the inspection.

LPA toured inside and outside of the facility. Facility observed without any obstructions or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Administrator certificate is valid.

The following deficiencies were observed:
1. Fire extinguisher last purchased 10/8/2020.
2. LPA observed black mold in east hall bathroom bathtub caulking, in caulking of tiles around bathtub spout, and soap scum on tile wall surround; black mold in grout lines of tile wall surround in west hall bathroom; and east hall bathroom shower head observed with brown residue.
3. Hot water in east hall bathroom measured at 100.9 degrees F

The following forms are to be submitted to CCL within two weeks: LIC500, LIC610E

Deficiencies are being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee Honora Gamueda, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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 3
Document Has Been Signed on 08/30/2022 08:28 AM - It Cannot Be Edited


Created By: Malia Thao On 08/25/2022 at 10:28 AM
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: VALLEY CHRISTIAN HOME II
FACILITY NUMBER: 107200719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed black mold in east hall bathroom bathtub caulking, in caulking of tiles around bathtub spout, and soap scum on tile wall surround; black mold in grout lines of tile wall surround in west hall bathroom; and east hall bathroom shower head observed with brown residue, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Licensee will submit proof of new caulking for bathtub and tiles around spout of east hall bathroom, shower head cleaned in east hall bathroom, and grout lines in tile wall surround in west hall bathroom cleaned to CCL by POC due date.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Hot water in east hall bathroom measured at 100.9 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Licensee will submit proof of hot water in east hall bathroom measuring within range to CCL by POC due date.
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:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2022 08:28 AM - It Cannot Be Edited


Created By: Malia Thao On 08/25/2022 at 10:47 AM
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: VALLEY CHRISTIAN HOME II
FACILITY NUMBER: 107200719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Fire extinguisher last purchased 10/8/2020, which poses an immediate safety or personal rights risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Licensee will submit proof of newly purchased fire extinguisher to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
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