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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202659
Report Date: 07/27/2022
Date Signed: 08/01/2022 03:40:39 PM

Document Has Been Signed on 08/01/2022 03:40 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:LEONIE HOUSEFACILITY NUMBER:
107202659
ADMINISTRATOR:KENDAKUR, SUNDARIFACILITY TYPE:
740
ADDRESS:2931 CAESAR AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 6DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Administrator, Sundari "Susan" KendakurTIME COMPLETED:
02:37 PM
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On 7/27/2022 Licensing Program Analyst (LPA) M. Garza arrived at the facility for an unannounced Infection Control/Annual visit. LPA introduced self and was COVID pre-screened. Administrator, Susan Kendakur was contacted and arrived some time later. A health and safety check was completed on residents in care. Residents observed in common areas. 6 residents present during the inspection.

Visitor log-in/temperature check was observed upon entry but LPA was not logged into book. Hand sanitizer was readily available at check in but no additional observed throughout facility. A 30-day PPE supply not observed. Client restrooms toured, observed to be free from debris and operational. LPA observed hand washing posting by all sinks. Social distancing is maintained in the common areas. LPA observed social distancing and cough etiquette postings in facility.

Facility maintained at a temperature of 75 degrees F. No passageway obstructions or fire hazards were observed inside or outside. Fire extinguisher observed with an expiration date of 06/01/2023.

Client files have updated emergency contact information and staff files have current CPR/1st Aid training.

The following documents are requested and to be submitted to Fresno CCL by: 07/29/22. The following updated forms were requested: LIC308, LIC309 (if applicable), LIC500, LIC 610D, LIC9020, and updated Administrator certificate.

TA provided for infection control, maintenance/operations, personal accommodations/services. Deficiencies cited on LIC 809-D.

Exit interview completed. A copy of this report/TA's and appeal rights were provided to Administrator.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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Document Has Been Signed on 08/01/2022 03:40 PM - It Cannot Be Edited


Created By: Mary Garza On 07/27/2022 at 02:02 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: LEONIE HOUSE
FACILITY NUMBER: 107202659

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 2 out of 3 hallways did not have night lights in the passageways. This posesd a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee to purchase night lights for hallways and provide receipts by POC 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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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