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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208910
Report Date: 06/21/2022
Date Signed: 06/24/2022 07:33:09 AM

Document Has Been Signed on 06/24/2022 07:33 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:
06/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Program Director, Lester ManigqueTIME COMPLETED:
03:37 PM
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On 06/21/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a Plan of Correction visit. LPA was greeted by Staff S1, explained the purpose of the visit as was allowed entry. COVID precautionary measures were taken at the time of entry.

The purpose of this visit is for LPA to provide POC completion. LPA received requested information from the 05/31/2022 visit evidencing the POC had been completed.

LPA interviewed Resident R1 who stated they have received their P&I monies for May 2022 and June 2022. P&I monies are being directly issued to a bank card from the payee service, which R1 now has and maintains possession of their own money.

Letters of Deficiency Citations Cleared provided to Program Supervisor.




SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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