<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206875
Report Date: 04/29/2022
Date Signed: 04/29/2022 09:25:22 AM


Document Has Been Signed on 04/29/2022 09:25 AM - 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: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:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Petro CrisostomoTIME COMPLETED:
09:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/29/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Lourdes “Carol” Morgan, Caregiver. Administrator Petro Crisostomo was called and arrived shortly and conduct tour with LPA. All six residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings.

LPA checked residents’ locked medications. LPA observed 30 day PPE supplies. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the laundry room. All resident’s room toured and observed to be adequately furnished and lit. LPA observed two shared residents’ bed to be at least 6 feet apart and two single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting not observed by bathroom sinks.

The exterior tour was conducted. Side gate was self-closing and free of obstruction. Staff records were reviewed for good health and infection control training. All six resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 5/5/22. The following updated forms were requested: Lic 308, Lic 610E, Lic 9020, control of property, and current liability insurance. A copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1