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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206875
Report Date: 04/05/2023
Date Signed: 04/05/2023 10:17:38 AM


Document Has Been Signed on 04/05/2023 10:17 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
SIERRA CASCADE AC/SC, 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:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Administrator Petro CrisostomoTIME COMPLETED:
10:30 AM
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On 4/5/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA was greeted by staff Lourdes “Carol” Morgan. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. Administrator Petro Crisostomo was called and arrived shortly. All six residents were present during the inspection.

The tour started in the common areas into the kitchen to resident's rooms and bathroom. LPA observed COVID-19 related signs. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 01/24/23. Medications are kept locked in medication cart. Temperature tested for refrigerator at 39 degree F. and freezer at -2 degree F. An adequate supply of perishable and non-perishable food was observed to be properly stored. Cleaning chemicals are kept in locked in laundry room closet. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lightning. LPA observed 2 shared residents’ bed to be at least 6 feet apart and 2 single occupant room. All bathroom are observed with securely fastened grab bars and non-skid mat. Bathrooms hot water temperature was tested at 111.1-degree F. in shared bathroom and 110.9 -degree F in bathroom 1. LPA observed trash can with lid and hand washing signs.The exterior tour was conducted. Side gate was self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. Half of the residents’ file reviewed to have update emergency contacts, Admission agreement, and physician report. A sample staff files were also reviewed. Staff files were observed to have current First Aid/CPR, Personal Record, and TB results. First aid kit was observed and contained all required items.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 4/11/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 808, Lic 9282, current liability insurance, control property, and current Administrator certificate. A copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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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