<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208860
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:24:50 PM

Document Has Been Signed on 10/27/2021 03:24 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:A PLUS BOARD AND CARE HOMEFACILITY NUMBER:
107208860
ADMINISTRATOR:TIBURCIO, RAULFACILITY TYPE:
740
ADDRESS:6757 E. CHRISTINE AVENUETELEPHONE:
(559) 493-9141
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 6DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Raul Tiburcio, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/27/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Administrator, Raul Tiburcio. All six residents were present during the inspection. LPA conducted tour with administrator.

Facility staffs was observed with mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility. All bathrooms are observed with trash cans with lid and securely fastened grab bars. Bathrooms have non-skid mat. LPA observed hand washing posting by all sinks. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 6 bedrooms that are single occupant.

LPA checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage.

The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed fire extinguisher served date: 06/20/21. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 11/2/21. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, and Lic 9020. LPA received copy of Administrator Certificate during facility inspection.

Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1