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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206561
Report Date: 11/23/2021
Date Signed: 11/23/2021 01:27:40 PM

Document Has Been Signed on 11/23/2021 01:27 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:SUNNY GARDENFACILITY NUMBER:
107206561
ADMINISTRATOR:SANTOS, CARLOFACILITY TYPE:
740
ADDRESS:3033 E. LOS ALTOS AVETELEPHONE:
(559) 439-5760
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 5DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Norrine Porciuncula, CaregiverTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. Administrator Carlo Santos was available via telephone and designated Caregiver Norrine Porciuncula to sign the annual report. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned. Hand sanitizer was readily available to clients and visitors. Social distancing is maintained in the common areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathroom and kitchen sink. The exterior tour was conducted.

Cleaning and PPE supplies were checked. Client’s files have updated emergency contact information. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Administrator certification is current.

Deficiencies are cited in LIC809D.

Designated Caregiver was provided with LIC809, LIC809D and Appeal Rights. Exit interview was conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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 11/23/2021 01:27 PM - It Cannot Be Edited


Created By: Lady Cabrera On 11/23/2021 at 12:50 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: SUNNY GARDEN
FACILITY NUMBER: 107206561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021

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

87309(a) Disinfectants, cleaning solustions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 LPA observed cleaning chemicals spray bottle under unlocked bathroom and kitchen sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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Care Staff immediatley removed cleaning chemical spray bottles to locked cabinet. POC cleared during visit.
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: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/23/2021 01:27 PM - It Cannot Be Edited


Created By: Lady Cabrera On 11/23/2021 at 12:59 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: SUNNY GARDEN
FACILITY NUMBER: 107206561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021

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 observations, the licensee did not comply with the section cited above. LPA observed backyard and west side fence supported by 2in x 4in post beams, and LPA observed serveral unused and old furniture items in the patio area. Facility's trees need to be maintained. Licensee did not ensure to maintain backyard facility clean and safe, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2021
Plan of Correction
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Licensee shall remove all items and will maintained the backyard clean, safe and sanitary. Licensee will submit pictures of the backyard by 12/03/2021 to CCL. Licensee will provide written letter indicating what is the plan to repair the fence by 12/3/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021


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: SUNNY GARDEN
FACILITY NUMBER: 107206561
VISIT DATE: 11/23/2021
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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
· 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: 12/03/2021.

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: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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