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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208954
Report Date: 12/18/2023
Date Signed: 12/18/2023 01:17:21 PM

Document Has Been Signed on 12/18/2023 01:17 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: 6CENSUS: 2DATE:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Facility Staff, Mryna NoblezaTIME COMPLETED:
01:32 PM
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On 12/18/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff informed LPA that Administrator is not available. LPA spoke with Administrator, John Nobleza via telephone. Administrator is unable to attend this inspection, LPA received verbal permission to meet with Facility Staff, Mryna Nobleza.

There are 2 residents present during today's inspection. LPA reviewed resident records and personnel records. Medication records reviewed. Medications observed to have original labels and be administered as prescribed. Last fire drill was conducted on 09/28/2023. Fire extinguisher last serviced 07/17/2023.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 115.3 degrees F. Kitchen toured, appeared clean, LPA observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching. Smoke detectors and carbon monoxide detector observed to be operational during today's inspection. Cleaning supplies is stored in a cabinet in the garage.

No deficiencies issued. Exit interview conducted and a copy of this report was discussed and will be provided to the Administrator via email due to technical issues. Report signed on-site by facility staff, Myrna Nobleza.

LPA is requesting the following documents be submitted to the Fresno CCL office by 01/08/2024: 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.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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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