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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209484
Report Date: 10/18/2024
Date Signed: 10/18/2024 04:28:55 PM

Document Has Been Signed on 10/18/2024 04:28 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:REDUBLA SENIORS CAREHOMEFACILITY NUMBER:
107209484
ADMINISTRATOR/
DIRECTOR:		REDUBLA, JENNIFERFACILITY TYPE:
740
ADDRESS:8455 N ARMSTRONG AVETELEPHONE:
(559) 939-3814
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 0DATE:
10/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator - Jennifer RedublaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 10/18/2024, Licensing Program Analyst (LPA) M Vega conducted an announced Pre-licensing / Component III Inspection for pre Licensing. LPA introduced self, stated the purpose of the visit, and was allowed entry into the facility. LPA met with Administrator 1 (A1) Jennifer Redubla LPA tour facility with A1.

The facility is a 4 bedroom and 2 bathroom home and fire clearance were granted for 6 Non-Ambulatory for a
total capacity of 6. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available.
Kitchen observed to have dishes, plates, utensils. Knives was kept locked and secure in kitchen drawers. LPA observed a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. Refrigerator temperature observed maintained at 34 degree F and freezer temperature maintained at -7 degree F. Cleaning supplies and chemicals observed to be locked under kitchen sink and in laundry room. A fire extinguisher was observed and had a service date of 08/24/24. First aid kit was observed and contained all required items. Bedrooms were observed to have the required furnishing and are ready for occupancy. Bathrooms were observed functional and operational during inspection. LPA observed a supply of extra bed linens and personal hygiene and grooming products. Outside of facility toured. Exits were open and free of obstructions. LPA observed adequate outdoor seatings available for residents. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Component III was conducted during today's pre-licensing visit.

Pre-Licensing is complete and this facility has no deficiencies.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB
in Sacramento for final review prior to license being issued.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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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