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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209048
Report Date: 03/05/2025
Date Signed: 03/05/2025 05:17:12 PM

Document Has Been Signed on 03/05/2025 05:17 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:RIVER BLUFFS MEMORY CARE COMMUNITYFACILITY NUMBER:
107209048
ADMINISTRATOR/
DIRECTOR:		HURLEY, DONNAFACILITY TYPE:
740
ADDRESS:5425 W. SPRUCE AVE.TELEPHONE:
(559) 840-9347
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 36CENSUS: 33DATE:
03/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:58 PM
MET WITH:Alexis MartinTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown is at the facility to conduct a Case Management visit in conjunction with a complaint investigation. LPA met with Wellness Director Alexis Martin (LVN) as Administrator (AD) Donna Hurley was unavailable at the time of visit.

During this visit, LPA observed the following:
1. A sharp cooking knife was left in a drying rack in the facility kitchen. The knife was not secured or locked.
2. A bottle of bleach was left out on the counter of a laundry room counter. The room was unlocked and the door found ajar.
3. A housekeeping cart was left unattended in the hallway leaving cleaning and disinfecting supplies accessible.

The items listed above were immediately removed and locked as required.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D, Section Storage Space and Access.

The deficiency was cleared during this visit. An exit interview was conducted and a signed copy of this report and Appeal Rights were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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 03/05/2025 05:17 PM - It Cannot Be Edited


Created By: Katie Brown On 03/05/2025 at 04:31 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: RIVER BLUFFS MEMORY CARE COMMUNITY
FACILITY NUMBER: 107209048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2025
Section Cited
CCR
87309(a)

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87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives..., are in locked storage and are not left unattended if outside the locked storage.This requirement was not met as evidenced by:
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During the visit, the knife was removed and locked, bleach and housekeeping cart containing cleaning supplies were locked and secused.
DEFICIENCY CLEARED DURING VISIT
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Licensee did not ensure a sharp cooking knife in the kitchen, bottle of bleach in a laundry room and an open housekeeping cart were locked and inaccessible to residents in care.
This poses an immediate health and safety 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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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