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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206579
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:45:19 PM


Document Has Been Signed on 04/14/2022 12:45 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: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:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator, Jelyn PinoTIME COMPLETED:
12:55 PM
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On 04/14/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Administrator, Jelyn Pino granted LPA entry to the facility. Facility has on central entry and exit and has implemented a sign in policy for visitors. There are 6 residents present during this inspection.

LPA toured the interior and exterior of the facility with Administrator. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms did not have trash cans with lid. Hand washing posters were observed by the bathroom sink. The facility has 4 resident bedrooms. Two bedrooms are shared and 2 are single occupant. Beds in the shared bedrooms observed to be at least 6 feet apart.

LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/28/2022: 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 were observed. Exit interview was conducted. A copy of this report was discussed and provided to Administrator, Jelyn Pino, whose signature on this form confirms receiving this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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