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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206579
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:04:16 PM

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:BLUE PEARL HOME CARE IIIFACILITY NUMBER:
157206579
ADMINISTRATOR:PINO, JELYNFACILITY TYPE:
740
ADDRESS:10414 BICHESTER COURTTELEPHONE:
(661) 412-8079
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 6DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Licensee, Petro CrisostomoTIME COMPLETED:
03:03 PM
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Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Visit. LPA Williams met with Licensee, Petro Crisostomo and discussed the purpose of the visit.

LPA Williams toured the facility with the Licensee.

LPA Williams observed a visitor log and disinfection station at the front entrance. Facility has one entry and exit point. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA Williams observed facility staff wearing masks.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. LPA Williams observed the following supply of personal protective equipment; gloves, goggles, and masks.

LPA Williams observed staff training records regarding Covid-19 mitigation and infection control. Resident’s files have updated emergency contact information.

No deficiencies were cited.

Exit interview was conducted with the Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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