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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206875
Report Date: 06/29/2021
Date Signed: 06/29/2021 12:20:17 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:DEVOTED HOME CARE, LLCFACILITY NUMBER:
157206875
ADMINISTRATOR:AGUIL, AMILYNFACILITY TYPE:
740
ADDRESS:10106 COBBLESTONE AVENUETELEPHONE:
(661) 858-0862
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 6DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Petro CrisostomoTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Melinda Medina conducted an unannounced Annual Visit. LPA Medina met with Administrator, Petro Crisostomo and discussed the purpose of the visit.

LPA Medina conducted facility tour with Administrator. Facility maintains a visitor log and disinfection station at front door. Front door is the facility only 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 common areas and bathrooms of facility.

LPA observed facility staff wearing masks. During facility tour, LPA observed adequate food supply to meet resident needs. Facility has a supply of personal protective equipment which includes, gowns, masks, face shields and gloves available.

LPA Medina observed a binder which included 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 Administrator. LPA will e-mail a copy of this report to Administrator.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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