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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208910
Report Date: 05/31/2022
Date Signed: 06/01/2022 08:32:19 AM

Document Has Been Signed on 06/01/2022 08:32 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:VILLA HERMOSAFACILITY NUMBER:
157208910
ADMINISTRATOR:SAYSON, SHANNONFACILITY TYPE:
735
ADDRESS:10808 VILLA HERMOSA DRTELEPHONE:
(661) 203-2116
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 4CENSUS: 3DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Program Director, Lester Manigque TIME COMPLETED:
07:30 PM
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On 05/31/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct an annual infection control inspection. LPA was met by Staff S1, stated purpose of the visit and was allowed entry into the facility. Administrator for facility is Dante Williams. Staff S2 responded to the facility to assist with the inspection. Staff S2 has a signed LIC 308 (Designation of responsibility) form signed by the Administrator. LPA began the tour at the front entrance/office of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked door in garage and a locked cabinet in the laundry room. LPA observed the following personal protective equipment in a storage cabinet in laundry room; gowns, face shield, gloves, and masks.
No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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