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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209181
Report Date: 12/15/2022
Date Signed: 12/15/2022 02:15:37 PM


Document Has Been Signed on 12/15/2022 02:15 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:CROMWELL HAVENFACILITY NUMBER:
107209181
ADMINISTRATOR:YOLANDA CASTIGADORFACILITY TYPE:
740
ADDRESS:5787 W. CROMWELL AVE.TELEPHONE:
(925) 470-9712
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 5DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Percival TobiasTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Inspection - Infection Control. LPA met with and explained the purpose of the visit with Administrator (AD) Percival Tobias.

LPA toured the facility inside and out. Upon entry, LPA observed visitor sign in and temperature check, available masks and sanitizer. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed soap, paper towels and hand washing signs in bathrooms. LPA observed required food supply, paper products, available PPE and resident medications. Cleaning/disinfecting products and sharps/knives were locked. LPA reviewed resident emergency contact information. Fire and Carbon Monoxide alarms were observed in working order. LPA observed fire extinguisher which was purchased 5/2/22. AD certificate expires 10/17/23.

AD has agreed to revise the symptom screening forms for residents, visitors and staff.
No deficiencies were cited during this inspection.



An exit interview was conducted. A copy of this report was left with Percival Tobias whose signature confirms receipt of these documents.

LPA requested the following updated forms by 12/22/22: LIC 308, LIC 500, LIC 610E,
LIC 9020,a copy of current Liability Coverage and revised screening forms.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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