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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208832
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:15:38 PM


Document Has Been Signed on 04/25/2022 03:15 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:COBBLE STONE RESIDENTIAL HOME CARE LLCFACILITY NUMBER:
157208832
ADMINISTRATOR:CLARK, CATHERINEFACILITY TYPE:
740
ADDRESS:9320 COBBLE MOUNTAIN ROADTELEPHONE:
(661) 397-0885
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:6CENSUS: 3DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator Catherine ClarkTIME COMPLETED:
02:45 PM
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On 04/25/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Staff George Milarion. Administrator Catherine Clark was contacted via phone and requested to come to the facility to assist with the inspection.

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Hand washing signs were observed in the Bathrooms.

Facility tour conducted with Staff. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. Facility staff observed with facial coverings. The fire extinguisher was observed with a service date of: 6/24/2021. Bedrooms were observed to have adequate lightning and required furniture and bedding. Bathrooms were properly equipped with non-skid mats, and securely fastened grab bars. LPA toured the kitchen and observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA observed a 30-day supply of PPE and cleaning supplies. Chemicals and cleaning supplies were stored in a locked laundry room cabinet. Medications were observed in a locked cabinet in the kitchen. No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 05/2/2022: Current
copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization
(LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan,
Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. As a COVID-19 precautionary measure, a copy of this
report will be provided via email. Report signed on-site by Administrator Catherine Clark.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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