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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202449
Report Date: 01/17/2023
Date Signed: 01/17/2023 10:50:44 AM

Document Has Been Signed on 01/17/2023 10:50 AM - 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:PTS FOURFACILITY NUMBER:
157202449
ADMINISTRATOR:GONZALEZ, CARLOSFACILITY TYPE:
735
ADDRESS:9207 BLOSSOM TIME AVENUETELEPHONE:
(661) 496-8188
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 4CENSUS: 4DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Licensee Judith Gonzalez and Administrator Mariana Rodriguez TIME COMPLETED:
11:00 AM
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On 01/17/23, Licensing Program Analyst (LPA) Yang arrived unannounced and to conduct an Annual Inspection- Infection Control. LPA knocked on the door, no one answered at the door nor did LPA Yang hear any movement inside. LPA contacted Administrator Carlos Gonzalez via telephone and left a voicemail requesting Administrator return the call at approximately 09:42 AM. At approximately 09:55 AM, Licensee Judith Gonzalez arrived at facility. LPA was introduced self, stated the purpose of the visit, and was granted entry into the facility. There are no client present during inspection. Administrator Mariana Rodriguez arrived shortly. LPA toured facility with Administrator.

Upon entry facility staff was observed with facial mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction. Social distancing is maintained in the common and dining areas. LPA observed cough etiquette postings in facility.

Food supply was checked. Food supply was checked and appeared to be an adequate supply. All clients’ room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant. All bathrooms observed trash bin with no lid. LPA observed hand washing posting by bathroom sink. LPA observed fire extinguisher served date: 11/4/22. LPA observed a small amount of PPE supplies which included: surgical mask, and gloves. Cleaning chemicals stored and locked in garage cabinet. The exterior tour was conducted. Side gate clear from debris. Staff records were reviewed for good health and infection control training. All client records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 1/23/23. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610D, Lic 9282, control of property, and current Administrator Certificate. A copy of this report was provided to the Administrator.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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