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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209412
Report Date: 04/26/2024
Date Signed: 04/26/2024 02:33:21 PM

Document Has Been Signed on 04/26/2024 02:33 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:A PLUS ASSISTED LIVING FOR ELDERLYFACILITY NUMBER:
107209412
ADMINISTRATOR/
DIRECTOR:		TIBURCIO, RAUL G.FACILITY TYPE:
740
ADDRESS:5490 E BUTLER AVETELEPHONE:
(925) 234-3371
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 0DATE:
04/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Raul Tiburcio, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:38 PM
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Licensing Program Analyst (LPA) Lissett Padgett arrived announced to conduct a Pre-Licensing inspection. LPA met with Licensees Raul Tiburcio and Connie Tiburcio. Home has 6 bedrooms and 4 bathrooms. Licensees are requesting capacity of 6 residents. Home and grounds toured with Licensees.

Smoke and carbon monoxide detectors (combo alarm) tested and operational; they are hardwired to the other smoke detectors in the bedrooms and common areas. LPA observed all sounded when one was tested.
Living room has screened fireplace with stove insert. Licensee states they will not be using the fireplace. LPA observed a love seat and two chairs in the living room and a dining table with seating for 4.

Kitchen observed to be to have appliances in good repair. Refrigerator temp measured at 35 degrees F. Dishware and utensils sufficient for 6 residents observed. Knives are stored in lock box on kitchen counter. Medications will be centrally stored in designated to locked kitchen cabinet. Pantry observed to have adequate supply of dry goods and emergency supply of food.

Ample supply of linens, towels and toiletries, including incontinence pads observed in hall closets. Facility thermostat observed to be 69 degrees. Licensees explained that HVAC unit is not functioning.

Bedroom 1 has a private bathroom, water temperature measured 113.5. Bathroom has grab bars at the toilet and in the shower. Non Skid mat available. Toilet flushed and is functioning. LPA observed room to be furnished with full size bed, dresser, night stand, trash can with lid.

Bathroom 2 observed to have required items, Shower and toilet grab bars installed, raised toilet seat, supply of paper towels and toilet paper. Water temp measured at 115.0 degrees F.

Bedrooms 2-6 observed to have sufficient space and were furnished with required furniture. Windows operable with screens in good condition. Bedroom 3 has been allocated as a bedridden room.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: A PLUS ASSISTED LIVING FOR ELDERLY
FACILITY NUMBER: 107209412
VISIT DATE: 04/26/2024
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Bathroom 3 located in hallway observed to have grab bars in shower and next to toilet, non skid mat. LPA observed shower tub to have orange mold and the tub was dirty. Shower curtain also had orange mold and felt slimy.

The bathroom in bedroom 4 observed to have functioning toilet, shower and toilet grab bars and non skid mat, trash can with lid. The water in the sink faucet comes out slow and less than pencil width. Licensee explained that he will repair this faucet.

Laundry room has a locked door. LPA observed washer and dryer and detergents and cleaning supplies in cabinets.

Per Licensee, the garage area will be kept locked and inaccessible to residents. Garage contains extra hygiene supplies, extra furniture and miscellaneous items. Licensee has sectioned a locked portion of the garage to contain gardening tools.

The Licensee has divided the backyard with a combination of chain link fence, wood plank fence and iron fence. The portion of the yard allocated for residence is paved and has two wheelchair ramps on either side leading to lower portion of the yard. The rear portion on the yard that is fenced off contains a swimming pool and overgrown grass/weeds. This fencing has one self latching gate with a combination lock and door alarm. Fencing varies in height from 5' to approximately 6 feet all around.
Side gate is self closing and self latching.

The following observed will need to be brought into compliance prior to licensure:
1. HVAC repair so that the Air Conditioning and Heating are functioning.
2. Clean shower in bathroom 3 to remove mold and replace shower curtain
3. Telephone service must be functioning
4. Remove licensee personal items/clothing from hall closet
5. Seating for at least 6 residents in the living room
6. seating for at least 6 residents at the dining room table
7. Move bed in room 2 so that it does not obstruct the window.
8. Set up room allocated as the Staff Lounge Area, so that the approximately 6" step down does not pose a fall risk to residents.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: A PLUS ASSISTED LIVING FOR ELDERLY
FACILITY NUMBER: 107209412
VISIT DATE: 04/26/2024
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9. Repair bathroom sink water faucet in bedroom 4 so that a full stream of water comes out.

A follow-up inspection to be scheduled once all above items are in compliance. Exit interview conducted.

A copy of this report was given to Licensees, whose signature confirms receipt of this report.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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