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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202514
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:29:09 PM

Document Has Been Signed on 12/07/2022 02:29 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:RENDERCAREFACILITY NUMBER:
107202514
ADMINISTRATOR:FLAUTA, VICTOR S.FACILITY TYPE:
740
ADDRESS:47 W. MENLO AVE.TELEPHONE:
(559) 325-6909
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 6DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Designated Representative and Staff Xandralie JacabaTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA spoke with Administrator Dr. Flauta and designated Jill Stowell to meet with LPA. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathrooms. Bedrooms were checked. The exterior tour was conducted.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Shortly, Designated Representative Jill Stowell had to leave the facility and designated Staff Xandralie Jacaba to sign this report.

Deficiency cited on LIC809D.

Exit interview was conducted. Appeal rights were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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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: RENDERCARE
FACILITY NUMBER: 107202514
VISIT DATE: 12/07/2022
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 12/17/2022

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2022 02:29 PM - It Cannot Be Edited


Created By: Lady Cabrera On 12/07/2022 at 02:10 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: RENDERCARE
FACILITY NUMBER: 107202514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above, chemicals and disinfectants, cleaning solutions were unlocked underneath the kitchen sink, bathroom #2 sink and laundry area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
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Cleared at the time of the visit. Administrator and staff immediately locked all chemicals and disinfectants.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2022 02:29 PM - It Cannot Be Edited


Created By: Lady Cabrera On 12/07/2022 at 02:14 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: RENDERCARE
FACILITY NUMBER: 107202514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) 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 and interviews, the licensee did not comply with the section cited above, Resident's (R1) room #4 had a strong urine odor, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Administrator will submit written cleaning and disinfecting plan for room #4 indicating how often they will deep clean the carpet or find another solution in order to maintain the room odorless due to R1’s condition by 12/09/2022.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022


LIC809 (FAS) - (06/04)
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