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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208977
Report Date: 06/21/2022
Date Signed: 06/21/2022 01:58:42 PM

Document Has Been Signed on 06/21/2022 01:58 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:JAN-ROY PLACE OF FRESNOFACILITY NUMBER:
107208977
ADMINISTRATOR:HOPPER, JOYCELYNFACILITY TYPE:
740
ADDRESS:4766 EAST ILLINOIS AVETELEPHONE:
(559) 940-9708
CITY:FRESNOSTATE: CAZIP CODE:
93702
CAPACITY: 6CENSUS: 4DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Administrator, Amor AlegreTIME COMPLETED:
02:20 PM
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 06/21/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Per facility staff, Administrator, Joycelyn Hopper is not available. Staff contacted Administrator, Amor Alegre, who arrived a short time later. LPA met with Administrator, Amor Alegre.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. LPA observed blinds to be broken and missing in the living room. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. The window screen in the resident bathroom was taped to facility. Resident bedrooms checked. Beds were observed to be at least 6 feet apart. LPA observed blinds to be broken and missing resident bedroom 1. Window screens in the resident bedrooms were stapled to the facility and not secure.

LPAs checked residents’ locked medications and observed a 30-day supply. Food supply was checked. LPA did not observe a two day supply of perishable foods. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Facility staff was observed wearing a facial covering. Residents wear masks when away from the community. LPA reviewed 4 out of 4 resident files.

LPA is requesting the following documents be submitted to the Fresno CCL office by 07/21/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond

CONTINUED TO 809C

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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 3
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: JAN-ROY PLACE OF FRESNO
FACILITY NUMBER: 107208977
VISIT DATE: 06/21/2022
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
26
27
28
29
30
31
32
Based on observation, deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted. A Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Amor Alegre, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/21/2022 01:58 PM - It Cannot Be Edited


Created By: Alexandria Walton On 06/21/2022 at 12:58 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: JAN-ROY PLACE OF FRESNO
FACILITY NUMBER: 107208977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022

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

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as evidenced by multiple blinds missing in multiple rooms of the facility, 2 window screens were not secure to the windows, and the window screen in the resident bathroom was taped to the faciliy which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
1
2
3
4
Licensee agrees to repair the missing blinds and secure the window screens by the POC due date.
Type B
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements: (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when the faciliy did not stock a two day supply of perishable foods for 4 out of 4 clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
1
2
3
4
Licensee agrees to stock the facility with a minimum two days supply of perishable foods and will submit a written statement detailing the steps the facility will take to ensure the requirements for section 87555 General Food Service Requirements are met to the Fresno CCL office by the POC due date.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3