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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208818
Report Date: 01/06/2022
Date Signed: 02/02/2022 11:59:55 AM

Document Has Been Signed on 02/02/2022 11:59 AM - 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lisa PuaTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Infection Control Annual Inspection. LPA met with Lisa Pua, Assistant Administrator. During the Annual inspection the following was observed:

Physical Environments and Accommodations:
1. Disinfectants, cleaning solutions and sharps were accessible to clients.

Food Services:
1.Spoiled/contaminated vegetables were found in the refrigerator. Spoiled food was discarded immediately.







Deficiencies are cited on the following 809-D.

A copy of this form including plan of correction and Appeal Rights were provided to Assistant Administrator. An Exit Interview was conducted.
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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Document Has Been Signed on 02/02/2022 11:59 AM - It Cannot Be Edited


Created By: Katie Brown On 01/06/2022 at 12:55 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: RIVERSIDE SENIOR CAREHOME
FACILITY NUMBER: 107208818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2022
Section Cited
CCR
87309(a)

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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.

This requirement was not met as evidenced by:
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POC CLEARED during visit: Disinfectants, cleaning supplies and knives that were not locked properly were immediately removed and placed in a locked cabinet until locks are repaired.
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Licensee did not ensure that that all disinfectants, cleaning solutions and sharps were inaccessible to clients. Cabints in the laundry room, kitchen and resident bathroom were found to have defective magnetic locks.

This poses an immediate health & safety risk to persons in care.
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Licensee has agreed repair or replace the locks on the cabinets throughout the facility. An in-service will be provided to all staff. Proof of lock repairs and in service will be provided to CCLD by 1/18/2022.

LPA contact information provided.
Type B
01/18/2022
Section Cited
CCR87555(b)(28)

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement was not met as evidenced by:
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Licensee has agreed to provide an in service to all staff to review the food service requirements as stated in section 87555 (b). Licensee will provide proof of in service in the form of a sign in sheet and copy of materials used to be provided to CCLD by 1/18/2022
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Licensee did not ensure that food was protected against contamination. Spoiled vegetables were found in the refrigerator.

This poses a potential health & safety risk to persons in care.
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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:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2022


LIC809 (FAS) - (06/04)
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