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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209316
Report Date: 03/14/2024
Date Signed: 03/15/2024 10:08:17 AM


Document Has Been Signed on 03/15/2024 10:08 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:TRINITY, THEFACILITY NUMBER:
157209316
ADMINISTRATOR:LAZAGA, JETHRONELFACILITY TYPE:
740
ADDRESS:200 TRINITY AVETELEPHONE:
(661) 563-1761
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY:10CENSUS: 8DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Jethronel Lazaga, AdministratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with Administrator, Jethronel Lazaga (AD) and explained the purpose of the visit. Facility was toured inside and outside with AD.
Resident rooms contained required furnishings and lighting. This facility has 6 resident bedrooms and 5 bathrooms. LPA observed required items in bathrooms with hot water measuring between 106.7.1 to 114.4 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed required food supply and paper products. Medications are centrally stored and locked in closet near the kitchen. Cleaning supplies are stored in locked laundry room. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit is located in medication storage closet and found to contain required items.
Fire Extinguishers are located throughout the facility and were serviced in 2/20/2024. Facility has a sprinkler system. Per Licensee, Smoke and Carbon Monoxide detectors are a combo alarm and are tested annually by AAA Quality Services fire safety company, the latest inspection was conducted on 2/20/2024. LPA conducted resident and staff file reviews and interviews.
An exit interview was conducted with AD.

LPA is requesting the following documents be submitted to the Fresno CCL office by 3/28/2024: 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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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