<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209275
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:40:26 PM


Document Has Been Signed on 01/30/2024 12:40 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: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:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Mark RivasTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Mark Rivas and Designee, Samantha Capistrano. There are no residents currently admitted to the facility.

During this visit, LPA toured the facility inside & out. Resident bedrooms contained required furnishings and lighting. The resident bathroom was clean, LPA observed required hygiene and safety items. Towels, extra blankets, and linens were available for use. Resident bathroom hot water temperature measured 109 degrees. The kitchen was clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications will be centrally stored in a locking cabinet in the kitchen. A First aid kit contained required items. The facility has designated visitation areas available inside and out. LPA observed a self-releasing gate and windows have screens in good repair. Smoke and Carbon Monoxide detectors present and in working order. A Fire extinguisher was purchased on 1/24/2024. LPA conducted a staff file reviews. The Emergency Disaster Plan and Infection Control Plans were reviewed. A resident admission binder was reviewed and contained copies of all required documents. Administrator Certificate Number 6060516740.

There were no citations during this inspection. An exit interview was conducted and a copy of this report was provided to Mark Rivas, whose signature confirms receipt.

LPA requested the following updated forms faxed to CCLD by 2/6/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Emergency Disaster Plan LIC610E, Personnel Report (LIC 500).
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1