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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208951
Report Date: 04/14/2022
Date Signed: 04/14/2022 11:27:04 AM

Document Has Been Signed on 04/14/2022 11:27 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:BUENA VISTA MANOR ARF INC.FACILITY NUMBER:
157208951
ADMINISTRATOR:BAGUIO, MIAFACILITY TYPE:
735
ADDRESS:11126 VISTA DEL VALLE DRIVETELEPHONE:
(661) 885-7838
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 3DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Caregiver, Walter Rios and Administrator, Mia BaguioTIME COMPLETED:
11:30 AM
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On 04/14/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Caregiver, Walter Rios granted LPA entry to the facility and contacted Administrator, Mia Baguio who arrived a short time later. Facility has one central entry and exit and has implemented a sign-in policy for visitors. There are 3 residents present during today's inspection.

LPA toured the interior and exterior of the facility with Caregiver Rios. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Bedrooms are single occupant.

LPAs checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/28/2022: 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 (LIC610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020), Surety Bond

No deficiencies were observed. Exit interview was conducted. A copy of this report was discussed and provided to Administrator, Mia Baguio, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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