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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209275
Report Date: 01/12/2023
Date Signed: 01/13/2023 10:57:11 AM


Document Has Been Signed on 01/13/2023 10:57 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:CENTRAL VALLEY RESIDENTIAL CARE, LLCFACILITY NUMBER:
157209275
ADMINISTRATOR:RIVAS, MARK JOSEPHFACILITY TYPE:
740
ADDRESS:6727 SHAVER DRIVETELEPHONE:
(626) 977-4093
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:6CENSUS: 0DATE:
01/12/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Administrator, Mark RivasTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Darius Williams conducted an announced visit regarding a Pre-licensing inspection. LPA Williams met with Administrator Mark Rivas and discussed the purpose of the visit. No clients were present or have been admitted.

LPA Williams toured the facility with the Administrator.

The tour began in the front of the facility. There were no obstructions or trip hazards.

Upon entrance to the facility LPA Williams observed various signs regarding infection control, personal rights, house rules, visitation, etc., posted. The living room had seating for up to 6 clients, had space to move around, and had lighting.

The kitchen had two tables with seating for 6 residents. The refrigerator temperature reflected 40 degrees Fahrenheit (F) and the freezer reflected 0 degrees F. The hot water from the kitchen faucet reflected approximately 105.1 degrees F. Cleaning chemicals are kept in a locked cabinet inaccessible to residents. Fire extinguisher reflected a service date of 9/7/2022.

There are three bedrooms with two beds each. All beds have a mattress, mattress cover, fitted sheet, sheet, blanket, pillow, and pillow cover. There were two night stands and a chair in each room.

There is one bathroom equipped with non-slip mats and grab bars. Towels are readily available to residents.

*Continued on LIC 9099-C*
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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: CENTRAL VALLEY RESIDENTIAL CARE, LLC
FACILITY NUMBER: 157209275
VISIT DATE: 01/12/2023
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The backyard has a covered area and was free of obstruction and trip hazards.

Smoke detectors and carbon monoxide detector were all operational. First aid kit was present and had all required items.

LPA Williams reviewed Component III with the Administrator.

Pre-Licensing is complete and the facility has no deficiencies. At this time no License has been issued. LPA Williams will forward this report to the Central Application Bureau for further action.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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