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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209006
Report Date: 08/12/2022
Date Signed: 08/12/2022 12:51:46 PM

Document Has Been Signed on 08/12/2022 12:51 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: 5DATE:
08/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Care Giver, Marites PaggaoTIME COMPLETED:
12:57 PM
NARRATIVE
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On 8/122/022 Licensing Program Analyst (LPA) M. Garza arrived at facility for a case management visit. This case management is being completed for a previous visit made to the facility on 6/15/2022. LPA met with Administrator, Pardeep Singh and was informed they were unavailable. Administrator gave permission for Care Staff, Marites Paggao to complete tour and sign report(s). Reason for visit was explained. LPA was COVID pre-screened at time of entry. LPA toured facility and completed a health and safety check on residents in care. Residents observed in common areas and in rooms.

During visit LPA requested to review R1’s file. R1’s file was unable to be located. Documentation was provided to CCL at a later date via email. Residents files must be retained at the facility/centralized location within a reasonable distance. Administrator stated they could retrieve files but would take them approximately 45 minutes to 1 hour to return. Deficiency cited on 809-D



An exit interview completed. A copy of this report and appeal rights was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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 08/12/2022 12:51 PM - It Cannot Be Edited


Created By: Mary Garza On 08/12/2022 at 12:32 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: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2022
Section Cited
CCR
87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
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Staff will have traiing for ditigital files to access. Staff to complete training on regulation. Training material and sign in sheet to be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA interview and observation. LPA reviewed facilities resident records. LPA requested R1’s file to which staff stated it was unavailable. This poses 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: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022


LIC809 (FAS) - (06/04)
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