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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208818
Report Date: 01/06/2022
Date Signed: 01/06/2022 01:46:24 PM

Document Has Been Signed on 01/06/2022 01:46 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:RIVERSIDE SENIOR CAREHOMEFACILITY NUMBER:
107208818
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:7435 N RIVERSIDE DRIVETELEPHONE:
(559) 412-8684
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 5DATE:
01/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:LIsaTIME COMPLETED:
11:53 AM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Designee/. LPA entered through the central entry point where health screening was conducted. Visitor policy, PPE and sanitizer was observed in the entryway.

Infection control procedures which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, residents and visitors), testing, visitation requirements, quarantine/isolation procedures, staffing, PPE and daily infection control procedures. All residents and live in staff are fully vaccinated, including boosters.

LPA toured the facility inside and out. Required postings as well as Covid-19 and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed 30-day resident medication as well as PPE supply. Common and resident bathroom sinks are stocked with liquid soap and towels washing.

Facility has agreed to revise and resume staff daily health screening log.


The following forms requested to be updated and submitted to LPA by 1/18/2022: LIC 308, 309 610, 500, 9020A, a copy of current Liability Insurance.


No deficiencies cited for Infection Control Annual Inspection.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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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