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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200719
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:18:58 PM

Document Has Been Signed on 08/08/2024 03:18 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:VALLEY CHRISTIAN HOME IIFACILITY NUMBER:
107200719
ADMINISTRATOR/
DIRECTOR:		GAMUEDA, HONORAFACILITY TYPE:
740
ADDRESS:504 W. MESATELEPHONE:
(559) 438-1009
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 5DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:17 PM
MET WITH:Facility Staff, Nancy MarianoTIME VISIT/
INSPECTION COMPLETED:
03:33 PM
NARRATIVE
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On 08/08/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Administrator is unable to meet during this inspection. LPA met with facility staff, Nancy Mariano.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 102.5 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable food and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 07/19/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 05/15/2024. LPA reviewed staff and client records. Medications reviewed and observed to have original labels and be administered as prescribed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 08/22/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), Surety Bond.

A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. 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 facility staff, Nancy Mariano, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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Document Has Been Signed on 08/08/2024 03:18 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/08/2024 at 03:06 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: VALLEY CHRISTIAN HOME II
FACILITY NUMBER: 107200719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 when hot water measured at 102.5 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee agrees to adjust the water temperature and bring the water temperature range between 105 degree F and 120 degree F. Licensee agreed to adjust the temperature and track the water temperature for 7 days. Licensee will submit a copy of the water log to the Fresno CCL office by the 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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
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