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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209054
Report Date: 05/24/2025
Date Signed: 05/24/2025 01:44:10 PM

Document Has Been Signed on 05/24/2025 01:44 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:WILLY HOMEFACILITY NUMBER:
157209054
ADMINISTRATOR/
DIRECTOR:		AGUSTO, STACYRAEFACILITY TYPE:
734
ADDRESS:3702 ABBEY ROADTELEPHONE:
6618437739
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 5DATE:
05/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:47 AM
MET WITH:StacyRae AgustoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 5/24/2025, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA introduced self, stated purpose of visit, and allowed entrance by Direct Care Staff. LPA met with Registered Nurse (RN), Gurpiar "Garry" Brar to commence inspection. Administrator, StacyRae,Agusto contacted by telephone and arrived a short time later to continue with inspection visit.

LPA conducted facility with RN. There are currently 5 residents residing in home. LPA observed all residents to be participating in activities with staff during inspection visit. All common areas of facility have adequate seating available All bedrooms for residents are private, bedrooms observed to have all required furnishings. Resident bathrooms toured, LPA observed bathrooms to have grab bars available, water temperature observed at 109 degrees F. Kitchen toured, facility observed to a 2-day supply of perishable and a 7-day supply of non-perishable food available. All knives observed to be locked and secured in kitchen cabinet. LPA observed 2 medication carts which are locked and secured. LPA observed the medical supply room and cleaning supply room to both be locked, secured, and inaccessible to residents.

Fire extinguishers present throughout facility with a service date of 2/28/2025. Smoke detectors and carbon monoxide detectors present and observed operational during inspection. Facility is equipped with sprinkler system. The last disaster drill and fire drill was conducted on 5/01/25 according to facility records.

Outside of facility toured. Facility has a shaded patio area with seating available. All exits open free of obstruction. No hazards observed.

Staff and resident files reviewed. No deficiencies observed or cited during today's inspection.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Melinda Medina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: WILLY HOME
FACILITY NUMBER: 157209054
VISIT DATE: 05/24/2025
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LPA received updated LIC 402 Surety Bond, 500 Personnel Report, LIC 610 Emergency Disaster Plan for Resident Care Facilities, and LIC 9020 Register of Facility Clients/Residents, and a copy of Administrator's Certificate.

Exit interview conducted. A copy of report provided to Administrator, StacyRae Agusto for facility records.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Melinda Medina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2025
LIC809 (FAS) - (06/04)
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