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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209054
Report Date: 05/31/2023
Date Signed: 05/31/2023 03:15:06 PM

Document Has Been Signed on 05/31/2023 03:15 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:WILLY HOMEFACILITY NUMBER:
157209054
ADMINISTRATOR:AGUSTO, STACYRAEFACILITY TYPE:
734
ADDRESS:3702 ABBEY ROADTELEPHONE:
(661) 843-7739
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 5DATE:
05/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Registered Nurse, Glenda Loyola
Administrator, Stacyrae Agusto		TIME COMPLETED:
12:59 PM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced annual inspection visit. LPA Williams met with Registered Nurse, Glenda Loyola (RN). RN had LPA conduct a temperature check and Covid survey prior to entering. Administrator Stacyrae Agusto arrived shortly after. Four clients were home participating in an arts and craft activity.

LPA toured the facility with the Administrator.

Living room was clean and had space to accommodate all clients. Ambient temperature reflected 72 degrees Fahrenheit (F) via facility thermostat.

The kitchen was clean and in good repair. Two day supply of perishable food and seven day supply of non perishable food was present. Water temperature reflected approximately 106.1 degrees F via facility thermometer.

Five bedrooms and two bathrooms were toured. The bedrooms had all required items and were clean and in good repair. The bathrooms had grabs bars, as needed, for clients, and modifications to meet bathing needs.

Cleaning chemicals were observed behind a locked door and cabinet. Medications were observed in two locked medication carts.

Fire extinguisher and dual smoke detector/carbon monoxide were present and operational.

*Continued on LIC 809-C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: WILLY HOME
FACILITY NUMBER: 157209054
VISIT DATE: 05/31/2023
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LPA Williams reviewed two client files. Medical assessments and health care plans were present in each file. Two staff files were reviewed and had all required documents present.

No deficiencies were observed during the visit.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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