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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202514
Report Date: 10/03/2024
Date Signed: 10/03/2024 05:42:56 PM

Document Has Been Signed on 10/03/2024 05:42 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:RENDERCAREFACILITY NUMBER:
107202514
ADMINISTRATOR/
DIRECTOR:		FLAUTA, VICTOR S.FACILITY TYPE:
740
ADDRESS:47 W. MENLO AVE.TELEPHONE:
(559) 325-6909
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 5DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator, Nancy Wade TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daiquiri Boyd arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by caregiver staff and explain the purpose of the visit. Administrator Jill Stowell (AD1) was called to come to the home, but she was in Merced and caregivers stated that she would be here in approximately an hour. LPA notified staff that I was going to proceed with the inspection while waiting. At 11:00 AM, LPA asked for arrival time of AD1 and was told she will not be able to make it. Administrator Nancy Wade phoned facility and stated that she would be able to come by in 20 minutes.

The residence was set at 78 degrees F temperature and free of passageway obstructions inside and outside. LPAs observed six bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition. Hot water temperature was measured at 106 degrees F. Bathrooms were clean, in two of the resident bathroom, there was no hand soap available.

Kitchen toured, supply of perishable and non-perishable food observed and food was stored properly. There was not enough fresh food present in proper food groups, to accommodate five residents for two days. Medication and knives are locked next to the kitchen area. Medication was properly logged. Medication was being crushed when given to the residents, which LPA did not find any doctors orders stating that this was allowed, in the five resident doctors orders. Cleaning supplies were locked under kitchen sink. Smoke detectors and carbon monoxide were checked and operating. Fire extinguishers were charged and was serviced on 04/04/24. Last fire drill completed on 2/2/23. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction. Two gates exiting the backyard area were observed, the west gate gets stuck on the cement and is difficult to open and the east gate will not open at all. Administrator will fix gates within two weeks.

During the visit a file review was conducted for residents and staff files. When reviewing staff files, it was found that there were documents missing. (continued on next page)

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: RENDERCARE
FACILITY NUMBER: 107202514
VISIT DATE: 10/03/2024
NARRATIVE
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Resident files were found to not have the most recent documentation available from doctor visits.

Administrator was offered TSP services and they were accepted. LPA to refer Rendercare and notify Licensee.



An exit interview was conducted, and a copy of this report was provided to Administrator along with appeal rights.


Deficiencies were cited on this date.

LPA requested the following updated forms faxed to CCLD by 10/17/24: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/03/2024 05:42 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 10/03/2024 at 05:12 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of 3 staff files reviewed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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4
Administrator immediately went to Licensing office and filed the Criminal Record Clearance Transfer request form and had it date and time stamped by Licensing staff.
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:Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/03/2024 05:42 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 10/03/2024 at 05:12 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that files provided were not complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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All files shall be made current. Administrator to notify LPA when this is complete.
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:Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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