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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206247
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:35:37 PM

Document Has Been Signed on 11/17/2022 02:35 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:PTS THREEFACILITY NUMBER:
157206247
ADMINISTRATOR:RAYA,LUISFACILITY TYPE:
735
ADDRESS:11113 SONOMA CREEK CTTELEPHONE:
(661) 679-4138
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 4CENSUS: 2DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Luis RayaTIME COMPLETED:
02:40 PM
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On 11/171/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self and allowed entrance by Administrator Luis Raya. All COVID precautions observed to be in place, staff observed to be wearing masks. Facility has a visitor sign in book, thermometer, hand sanitizer, and masks available upon entry.

There are currently two residents, one resident was present during today's inspection. Resident who attends Day program attends Monday - Friday 8:00 am - 2:30 pm.

Facility toured. Facility observed to have adequate lighting available, adequate seating available in all common areas. Resident rooms toured, residents observed to have all required furnishings. Kitchen toured. Food supply observed to be adequate for residents in care. Resident bathrooms appeared clean & fixtures are operational. Medications are stored and secured in hall closet and inaccessible to residents. Residents have a 30-day supply of medication available.

Cleaning supplies and hazardous chemicals are stored in a locked cabinet in the garage and are inaccessible to residents. Smoke detectors and Carbon Monoxide detector tested and observed operational during inspection. A fire extinguisher present with a service date of 3/22/2022. Facility is equipped with a fire pull alarm system. The last fire drill was conducted in 10/2022 according to facility records.

Administrator to submit updated LIC 500, LIC 9020, LIC 610 and copy of current Administrator Certificate to Fresno CCL office no later than 12/01/2022.

No deficiencies observed during this visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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