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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209006
Report Date: 06/15/2022
Date Signed: 06/15/2022 02:21:22 PM

Document Has Been Signed on 06/15/2022 02:21 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:RISING SUN CARE HOME INCFACILITY NUMBER:
107209006
ADMINISTRATOR:SINGH, PARDEEPFACILITY TYPE:
740
ADDRESS:154 N LIND AVETELEPHONE:
(559) 313-4515
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 6DATE:
06/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Administrator, Pardeep SinghTIME COMPLETED:
02:43 PM
NARRATIVE
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On 6/15/2022 Licensing Program Analyst(LPA) M. Garza arrived at facility to complete an initial 10-day complaint visit. LPA was met by Direct Care Staff, Marties Paggao. LPA introduced self and was permitted entry into facility. LPA was not COVID pre-screened. LPA toured facility and completed a Health and Safety check on residents in care. Residents were observed in rooms and in common areas having lunch.

During tour LPA observed the following concerns addressed in this case management visit: trash bins in restrooms were without lids, LPA observed a visitor log and hand sanitizer but was not COVID pre-screened upon entry, 2 staff present were not wearing a face coverings and Let Us Know poster is 8x10 in size.

The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care.


Exit interview completed. A copy of this report and appeal rights given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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 2
Document Has Been Signed on 06/15/2022 02:21 PM - It Cannot Be Edited


Created By: Mary Garza On 06/15/2022 at 01:14 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: RISING SUN CARE HOME INC
FACILITY NUMBER: 107209006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited
CCR
87470(b)(2)

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87470 Infection Control Requirements (a) (a) A licensee shall ensure that infection control practices are maintained as follows...
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Training will be completed with all staff to ensure infection control requirements are being followed. Administator to provide traiing material and sign in sheet once completed by POC date.
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This requirement was not met as evidence by LPA observation of trash bins without lids, LPA not COVID pre-screened upon entry, 2 staff present not wearing face coverings. This poses a potential Health and Safety risk to residents in care
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Type B
06/24/2022
Section Cited
CCR87468((2)(A)

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87468 Personal Rights (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows:(A)...(PUB 475)...shall be 20" x 26" in size...
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Administrator to aquire a 20x26 sized poster and post in common area. Administrator to provide CCL a picture once completed no later than POC date.
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This requirement was not met as evidence by: LPA observation of the Let Us Know poster is 8x10 in size posted in common area in frame. This is a potential Health and Safety or personal rights risk to residents 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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022


LIC809 (FAS) - (06/04)
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