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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206575
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:36:15 PM


Document Has Been Signed on 11/15/2023 12:36 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:DEAN'S CARE VILLA 110FACILITY NUMBER:
157206575
ADMINISTRATOR:SANTA MARIA, ELVIRA PFACILITY TYPE:
740
ADDRESS:13110 HINAULT DRIVETELEPHONE:
(661) 218-9151
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 6DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Administrator, John NoblezaTIME COMPLETED:
12:49 PM
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On 11/15/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was granted entry to the facility and facility staff contacted the Administrator. LPA met with Administrator, John Nobleza.

There are 6 residents present during today's inspection. LPA reviewed resident records and personnel records. Medication records reviewed. Medications observed to have original labels and be administered as prescribed. Last fire drill was conducted on 09/22/2023. Fire extinguisher last serviced 07/17/2023.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 118.6 degrees Fin the bathroom near bedroom 3 and 116.2 degrees F in the bathroom in the shared bedroom. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/29/2023: 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 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

No deficiencies issued.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, John Nobleza, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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