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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208925
Report Date: 03/21/2024
Date Signed: 03/21/2024 02:54:39 PM


Document Has Been Signed on 03/21/2024 02:54 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:NOBLE SERVANT HOMESFACILITY NUMBER:
107208925
ADMINISTRATOR:VIZCARRA, MARISELA D.FACILITY TYPE:
740
ADDRESS:4140 W. CAPITOLA AVETELEPHONE:
(559) 492-7005
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 3DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Marisela VizcarraTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Marisela Vizcarra.

During this visit, LPA toured the facility inside & out. Resident bedrooms are found in good repair, contained required furnishings and lighting. The resident bathrooms were clean and in good repair with faucets delivering hot water at 113 degrees. LPA observed required hygiene items and grab bars. Towels, extra bedding, and linens were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage. Knives/sharps, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored in a locked cabinet. A First aid kit contained required items. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. LPA observed a self-releasing gate and windows have screens in good repair. Smoke and Carbon Monoxide detectors were tested during the visit. The Fire extinguishers were serviced 9/6/23 by Valley Fire. LPA conducted resident and staff file reviews including medication audit.

There were no citations during this inspection.



An exit interview was conducted and a copy of this report was signed by AD and emailed to rn.helpinghands@gmail.com.

LPA requested the following updated forms faxed to CCLD by 3/29/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Emergency Disaster Plan (LIC610E), Personnel Report (LIC 500). Client Roster (LIC 9020), Proof of current Liability Coverage, Infection Control Plan including Infection Control Lead Certification.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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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