107209542-6-18-2025-24-AS-DBOD-DHRTCV-20250618143722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209542
Report Date: 06/18/2025
Date Signed: 06/18/2025 02:37:33 PM

Document Has Been Signed on 06/18/2025 02:37 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:	ANNAI HOUSE		FACILITY NUMBER:	107209542
ADMINISTRATOR/ DIRECTOR:	KENDAKUR, SUNDARI SUSAN		FACILITY TYPE:	740
ADDRESS:	175 W SIERA AVE		TELEPHONE:	(559) 779-4071
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY: 49		CENSUS: 29	DATE:	06/18/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Sundari Susan Kendakur		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/18/2025, Licensing Program Analyst (LPA) Daiquiri Boyd made an scheduled visit to the facility for the purpose of conducting a Pre-Licensing Inspection and Comp III. LPA was greeted by Licensee/Administrator Sundari Susan Kendakur. This facility is approximately 10,000 square feet and surrounded by a 6' tall perimeter iron fence with locked security gates. LPA began the tour by entering through the entrance gate off of the parking lot. There is a Ring doorbell that visitors must ring to be allowed entrance. No one can leave the property without being let out of the facility gate or off grounds except by a number key code, a key card that would scan or a physical key, which the four management staff, Administrators and office staff, kitchen staff, housekeeping staff and maintenance staff all have at least one of. The only staff who don't have a key during the day, is the caregiver staff, who do then receive a key in the evening hours once all of the day workers leave. There are 27 bedrooms, 4 showers that are for common use. There are 8 bedrooms that contain "Jack and Jill" bathrooms. Residents that shower independently use the showers in the room named the "Beauty Shop". Residents who needs assistance with showering, are taken to one of the bathroom areas that have shower chairs. Common living spaces are as follows; dining area, there is a TV room that has four couches and several recliners, there is a piano room which has two couches, a table and a piano. Flooring is intact throughout the facility. (continued on the next page)

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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: ANNAI HOUSE	FACILITY NUMBER: 107209542
	VISIT DATE: 06/18/2025

NARRATIVE

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Smoke detectors are located throughout the facility and the sprinkler system was tested by Clovis FD and found to be working properly. Four Carbon Monoxide detectors found to be in working order. The Fire Extinguisher was serviced on 7/2/24.
LPA observed a supply of extra bed linens, towels, and personal hygiene and grooming products. Resident rooms are found to be in good repair and contained required furnishings, and lighting. The resident bathrooms are clean and minor repairs were made on site.
The kitchen was observed to have a supply of dishes, plates, utensils and cooking items. Food storage areas are clear and appropriate for food preparation. Cleaning supplies, chemicals, and sharps/knives are locked as required. Appliances were found to be in working order. LPA observed the required food supply. Resident medications will be stored in a designated locking kitchen pantry closet. The First Aid kit contains all required items. Doors and passageways are unobstructed throughout the inside and outside of the facility.

Outside of the facility was toured. There is a covered seating area for the use of residents. Required postings are placed on a bulleting board. LPA requested that the Disaster and Emergency Plan be updated with additional details as well as the facility sketch.

LPA has concerns regarding the perimeter fence. The fence system is such that a person cannot enter or leave the facility without a person with a "key" to let them in or out. LPA Boyd reviewed the fire clearance and nothing is mentioned regarding delayed egress or the functioning of the outside locked perimeter gates.
LPA collect the LIC9020 Client Roster for review. This facility currently has 16 residents over 60 years of age and 13 under 60 years of age.
LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC809 (FAS) - (06/04)

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