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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208954
Report Date: 12/08/2022
Date Signed: 12/08/2022 12:08:24 PM


Document Has Been Signed on 12/08/2022 12:08 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:DEAN'S CARE VILLA 111FACILITY NUMBER:
157208954
ADMINISTRATOR:NOBLEZA, BASILISAFACILITY TYPE:
740
ADDRESS:13111 HINAULT DRIVETELEPHONE:
(661) 368-2489
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:3CENSUS: 3DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Administrator, John NoblezaTIME COMPLETED:
12:21 PM
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12/08/2022, Licensing Program Analyst (LPA) Walton arrived unannounced at the above facility to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, John Nobleza.

LPA conducted a facility tour with Administrator. COVID-19 guidelines are in place. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors at facility entrance. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lids. Hand washing posters were observed by the bathroom sink. Bedrooms are single occupant.

LPA 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. Resident’s files had updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/29/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator, John Nobleza, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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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