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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209412
Report Date: 06/27/2025
Date Signed: 06/27/2025 01:40:35 PM

Document Has Been Signed on 06/27/2025 01:40 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: 6DATE:
06/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:28 AM
MET WITH:Raul Tiburcio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On June 27, 2025 Licensing Program Analyst (LPA) Rachel Bruce arrived unannounced to conduct the required one year annual inspection. LPA was greeted by caregivers attending to resident lunches. The Administrator Raul Tiburico was called and arrived shortly. Currently the home has six residents and the home contains 6 bedrooms and 4 bathrooms.

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. There is one fire extinguisher located in the kitchen which was last serviced in July 2024. The first aid kit is located in kitchen next to the fire extinguisher and contained required items.

Living room has screened fireplace with stove insert which is non-operational. LPA observed adequate seating in living room for six residents and a dining table with seating for 5 and also available seating around the counter/bar in the kitchen adjacent to the table. There is also a common area to use for resident recreation. In that room are yard toys, pool table, computer and piano.

Kitchen observed to be to have appliances in good repair. Dishware and utensils sufficient for 6 residents observed. Knives are stored in a locked drawer in the kitchen. Medications are centrally stored in locked kitchen cabinet. Pantry observed to contain 7 day supply of non- perishable and emergency supply of food. 2 days of perishable food observed and stored appropriately in kitchen.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 06/27/2025
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Ample supply of linens, towels and toiletries, including incontinence pads observed in hall closets. Facility thermostat observed to be 72 degrees. Facility is maintained at a comfortable temperature. There are three temperature control zones in the home.

Bedroom 1 has a private bathroom, water temperature measured within regulatory range. 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. It was noted that water pressure when using the hottest setting is a little weak.

Bathroom 1 observed to have required items, Shower and toilet grab bars installed, raised toilet seat, supply of paper towels, toilet paper and covered waste container. Water temp measured within regulatory range. .

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 with fire door accessible to the outside.

Bathroom 3 located in hallway observed to have grab bars in shower and next to toilet, non- skid mat. Bathroom is clean and in good condition.

The bathroom in bedroom 4 observed to have functioning toilet, shower and toilet grab bars and non- skid mat, trash can with lid. Water pressure in sink faucet is normal. Water temperature in all bathrooms is within regulatory range.

Laundry room has a locked door to the hallway and staff access the laundry room from backyard door, which is also kept locked. LPA observed washer and dryer and detergents and cleaning supplies in cabinets.
There is an extra closet/storage area that remains locked and is used for staff personal items, not accessible to residents.

Per Licensee, the garage area is 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. Facility has a staff room, that will be accessible to residents as it is in an open space.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
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: 06/27/2025
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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. There is a covered patio which supplies shade. There is a garden area adjacent to the ramps for the residents to grow seasonal fruit and/or vegetables.

LPA conducted review of staff and resident files. All were found to be in compliance with CCR regulations. Staff files are located in locked office in hallway and the resident files were located in a locked built in cabinet in the common area.

An exit interview was conducted and a copy of this report was left with Applicant, whose signature confirms receipt of these documents
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
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