Your Loved Ones Matter

Type of visit: Required - 1 Year

On 08/27/2026, Licensing Program Analysts (LPAs) H Vang and M Vega arrived unannounced to conduct the Annual inspection. LPAs met with Assistant Administrator (AAD) - Raquel Jimenez and Staff 1 (S1). LPAs toured facility with S1 and AAD. There were two residents present at the time of visit, none are currently enrolled in day programs. Residents were resting in their rooms. During this inspection of the facility, the following was noted: Resident rooms were clean and contained required furnishings and lighting, However central ceiling fan in Room 4 was missing a blade. Window screens were present in every bedroom and were in good repair. LPAs observed required items in the two bathrooms with hot water measuring within regulatory requirements. Resident hygiene supplies were properly stored and available. The kitchen was toured and observed in good repair. Sharps/knives were improperly locked and stored in a kitchen cabinet accessible to residents in care. Emergency food and water supply stored in hallway closet along with overflow of non-perishable food items, Included food improperly stored some with freezer burn and other with no labels, carrots were sprouting. LPAs noted 2 days of perishable food and 7 days of non-perishable food. Menu posted on refrigerator and alternative menu items available. There are no residents with special dietary needs at this time. Medications are centrally stored and locked in hallway closet, closet doors missing knobs. Medication dispensing records stored and locked with employee and resident files. First aid kit contains required items and is located in hallway closet with medication. Continuation on LIC 809C Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. Outside physical plant issues include the following: electrical box with wires exposed, fire access gate non operational, and in front of house severe damage to exterior facia under kitchen window. Fire Extinguisher located in the kitchen was serviced on 08/04/2026. Smoke detectors in hall, kitchen and bedrooms were tested and Carbon Monoxide detector in hallway were tested -all were found to be operational. LPA reviewed 2 resident files and 2 staff files. Items were missing from both- see attached deficiency page for documentation of violation. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE) LIC 308 Designation of Facility Responsibility LIC 309 Administrative Organization LIC 400 Affidavit Regarding Client/Resident Cash Resources LIC 402 Surety Bond LIC 500 Personnel Report LIC 610E Emergency And Disaster Plan For Residential Care Facilities For The Elderly LIC 9020 Register of Facility Clients/Residents Copy of current Liability Insurance Copy of current Administrator Certificate Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 09/10/2026 As an operator of a Community Care Licensed facility, it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and a Plan of Correction was developed by Assistant Administrator. A copy of this report and Appeal Rights were discussed and left with AAD , whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 27, 2026

The state marks this report as 18 pages; the online copy we transcribed has 9. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rachel Bruce arrived unannounced to conduct the Annual inspection. LPA met with caregiver Guadalupe Jimenez (CG) and Raquel Jimenez, Administrator Assistant (ADA) and Caregiver. LPA toured facility with CG and ADA. All four residents were present at the time of visit, none are currently enrolled in day programs. One resident had family visitors at the time of the inspection who expressed they were pleased with the level of care that their husband/father was receiving. During this inspection of the facility, the following was noted: Resident rooms were clean and contained required furnishings and lighting. Window screens were present in every bedroom and were in good repair. LPA observed required items in the two bathrooms with hot water measuring within regulatory requirements. The resident bathroom had the following issues- Bathtub faucet was leaking, water stain/mold at bathtub faucet area, wooden board covering the bottom of bathroom sink needs to be replaced, hole in wall behind toilet, and handle missing on cabinet under sink. Hallway closets store linen and adequate supply noted. Resident hygiene supplies were properly stored and available. The kitchen was toured and observed in good repair. Sharps/knives were properly locked and stored in a kitchen cabinet. Emergency food and water supply stored in hallway closet along with overflow of non-perishable food items. LPA noted 2 days of perishable food and 7 days of non- perishable food. Menu posted on refrigerator and alternative menu items available. There are no residents with special dietary needs at this time. Medications are centrally stored and locked in hallway closet. Medication dispensing records stored and locked with employee and resident files. First aid kit contains required items and is located in hallway closet with medication. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. Outside physical plant issues include the following: Chicken coop to be removed, and warped and weathered facing boards at the front of the house are in need of replacement. Fire Extinguisher located in the kitchen was serviced in February 2024 and is need of reinspection. Smoke detectors in hall, kitchen and bedrooms were tested and Carbon Monoxide detector in hallway were tested -all were found to be operational. LPA reviewed 4 resident files and 4 staff files. Items were missing from both- see attached deficiency page for documentation of violation. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with ADA , whose signature on this form confirms receipt of these documents. LPA is requesting the following documents be submitted to the Fresno CCL office by 6/10/2025: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Liability Insurance, Emergency and Disaster Plan (LIC 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bondthe state’s words, verbatim · CDSS document, May 21, 2025

Type of visit: Case Management - Deficiencies

On February 19, 2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced case management visit for the purpose of addressing clearance of staff in the facility. During a recent inspection visit at the facility on February 7, 2025 LPA confirmed that an adult member of the family who turned eighteen on October 18, 2006 had not been finger print cleared to work in the facility. At today's visit, LPA was provided a copy of the live scan form completed for the adult family member which was completed on February 14, 2025. LPA confirmed that the son is indeed in LIS as cleared and is appropriately associated to the facility. He is now eligible to continue to work at the home. Deficiency and citation being issued at today's visit. Technical Advisory: Also during the visit today, LPA and Administrator discussed the fence in the backyard that is in need of repair. Administrator provided information that they are currently working on getting it fixed. LPA explained the need to have it repaired as soon as reasonably possible and to keep LPA appraised on the progress. No citation issued regarding buildings and grounds during today's visit.the state’s words, verbatim · CDSS document, Feb 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Feb 19, 2025

Criminal Record Clearance: (e) All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by Adult family member who turned 18 in October, 2024 was not cleared or associated to the facility at date of visit on February 7, 2025. This poses an immediate threat to the health, safety and/or personal rights of the residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: LPA verified that the family member is now finger print cleared and associated to the facility, Your Loved Ones Matter. POC to be cleared at today's visit.

Allegation investigated: Staff allow a resident to be soiled for extended periods of time

Licensing Program Analyst (LPA) Rachel Bruce conducted the subsequent complaint investigation visit to the facility for the purpose of delivering the finding on the above allegation that staff would allow a resident to be soiled for extended periods of time. During the course of this complaint investigation LPA interviewed staff on duty, outside parties, and obtained and reviewed facility records. It was determined based on the interviews, observations, and records review that the above allegation is SUBSTANTIATED. Facility staff did leave patient soiled for extensive periods of time because the resident did not want her diaper changed. Based on the LPAs investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report and appeal rights will be provided via email. Substantiatedthe state’s words, verbatim · CDSS document, Feb 7, 2025 · control 24-AS-20241016233013

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Feb 14, 2025

"Care and supervision" means the facility assumes responsibility for, or provides...ongoing assistance with activities of daily living without which the resident’s physical health... would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by the resident would refuse to get her diaper changed resulting in her being soiled for long periods of time resulting in an immediate risk to the health, safety or personal rights of the resident in care.the state’s words, verbatim · CDSS document, Feb 7, 2025

Plan of correction: Facility stated that they will train the staff that going forward they will contact the responsible party to intercede or assist with when a resident is refusing treatment or assistance. Ongoing assessment completed to ensure facility can meet client's needs.

Type of visit: POC

Licensing Program Analyst Lissett Padgett (LPA) conducted an unannounced POC visit with facility care giver Guadalupe Jimenez to verify correction of citations issued during the visit conducted on 4/25/2024. Licensee Isai Jimenez was called but was not able to arrive. Licensee gave permission for Guadalupe to sign this LIC809 . Deficiency cited on 4/25/2024,87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. LPA observed shower has cleaned, patio has been cleared of chicken feces. The glass shards have been cleaned and replacement has been ordered and will be installed today. Guadalupe showed this LPA verification from window installer of appointment scheduled for today. Deficiency 87303(c) All window screens shall be clean and maintained in good repair. LPA observed that the window screen has been replaced. Exit interview conducted with Guadalupe Jimenez and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 15, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with caregiver Guadalupe Jimenez (GJ) Administrator, Isai Jimenez (AD) was called and arrived shortly thereafter and explained the purpose of the visit. Facility was toured with GJ. During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting. LPA observed required items in the two bathrooms with hot water measuring between 110.3 to 107.2 degrees F. At 10:48am LPA observed what appeared to be dark colored mold on the shower floor, lower tiles and on non skid mat in bedroom 3. At 10:51am LPA observed the sliding glass door in bedroom 3 was shattered on the exterior pane. AD arrived later and explained that the gardener had accidentally shattered it a few days ago. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. Emergency food supply observed. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit reviewed and found to contain required items. Fire Extinguisher located in the kitchen was serviced in June 2023. Smoke detectors in hall, kitchen and bedrooms were tested and Carbon Monoxide detector in hallway was tested in found to be operational. LPA conducted resident and staff file reviews and interviews. LPA observed one staff member’s file to be missing health screening form. LPA toured the backyard. At 10:58am LPA observed chicken feces on the patio chairs. Licensee has pet chickens/roosters. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and emailed to AD, whose signature on this form confirms receipt of these documents. LPA is requesting the following documents be submitted to the Fresno CCL office by 5/3/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.the state’s words, verbatim · CDSS document, Apr 25, 2024

The state marks this report as 10 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff illegally evicted resident

Licensing Program Analyst (LPA) L.Padgett conducted an unannounced facility visit to deliver findings on the allegations listed above. Licensee was not able to meet with LPA and authorized care giver, Guadalupe Jimenez to sign this document. LPA reviewed finding with Licensee over the phone. During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Staff illegally evicted resident is UNFOUNDED. Resident R1 AWOL’d from this facility. Licensee did not issue an eviction notice to R1 and R1 was accepted back to the facility. This agency has investigated the complaint alleging Staff illegally evicted resident. We have found that the complaint was unfounded, therefore we have dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Apr 9, 2024 · control 24-AS-20240109144027

Allegation investigated: Staff did not accept resident back after hospital stay

Licensing Program Analyst (LPA) L.Padgett conducted an unannounced facility visit to deliver findings on the allegations listed above. LPA spoke with Licensee on the phone and reviewed findings. Licensee was not able to meet with LPA but authorized care giver, Guadalupe Jimenez to sign this document. Licensing Program Analyst (LPA) L. Padgett conducted the complaint investigation visit to the facility. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Staff did not accept resident back after hospital stay. Based on the interviews conducted and/or records review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Appeal rights provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 9, 2024 · control 24-AS-20240109144027