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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206674
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:07:52 PM


Document Has Been Signed on 09/26/2023 01:07 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:AIMES NOBLE IIFACILITY NUMBER:
157206674
ADMINISTRATOR:CORTEZ, JOSEFACILITY TYPE:
740
ADDRESS:5729 NOBLE STREETTELEPHONE:
(661) 589-9992
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:4CENSUS: 2DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Administrator, Jose CortezTIME COMPLETED:
01:22 PM
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On 09/26/2023, Licensing Program Analyst (LPA) arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Jose Cortez.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Resident rooms checked. 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 116.6 degrees F in the bathroom near bedroom 3 and 117.1 degrees F in the bathroom near bedroom 2. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 01/17/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted 09/15/2023. All cleaning supplies are locked and secured in a cabinet in the laundry room.

LPA reviewed staff and client records. Medications reviewed and observed to have original labels and be administered as prescribed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/10/2023: 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 (LIC9020A), Surety Bond

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Jose Cortez, 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: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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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