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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206579
Report Date: 07/14/2021
Date Signed: 07/15/2021 11:53:26 AM

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:
07/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Petro Chrisostomo, Administrator TIME COMPLETED:
02:15 PM
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On 07/14/21, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management inspection. LPA was greeted by Cargiver and allowed entry into facility. Administrator was called and arrived at the facility. LPA stated the reason of the visit was that CCLD received a call this morning stating Bakersfield Police Department (BPD) was at the facility. Administrator stated BPD conducted interviews but did not file a report or give an incident number.

LPA reviewed R1's LIC 602 Physician's report and conducted interviews with Administrator, Staff S1 and Resident R1.

No deficiencies cited on today's visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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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