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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209335
Report Date: 11/25/2024
Date Signed: 11/25/2024 11:35:57 AM

Document Has Been Signed on 11/25/2024 11:35 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:D VILLA ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
157209335
ADMINISTRATOR/
DIRECTOR:		NOBLEZA, BASILISAFACILITY TYPE:
735
ADDRESS:1709 D STREETTELEPHONE:
(661) 808-6081
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY: 25CENSUS: 25DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:11 AM
MET WITH:Administrator, Basilisa NoblezaTIME VISIT/
INSPECTION COMPLETED:
11:49 AM
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On 11/25/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff granted LPA entry to the facility and contacted Administrator, Basilisa Nobleza, via telephone. Administrator arrived a short time later. LPA met with Administrator.

LPA reviewed facility records and observed the following: Client and staff records observed to be current and complete. Emergency disaster plan reviewed. Last documented fire drill was conducted on 09/20/2024. Medication records reviewed. Medications were observed to be administered as prescribed. Smoke detector and carbon monoxide detector observed to be operational and were last serviced on 03/06/2024.

Facility tour conducted. All exits open and free from obstructions. Kitchen toured and observed to be safe for food preparation. LPA observed an adequate food supply. Bathrooms toured. Hot water measured at 112.4 degrees F. Resident bedrooms toured. LPA observed required furnishings and adequate lighting. Common areas and dining area were observed to be furnished well and had adequate lighting. Cleaning supplies and sharps/knives observed to be locked and inaccessible. Medications observed to be locked and inaccessible.

Exterior tour conducted. No fire clearance issues observed during today's inspection.

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Basilisa Nobleza, whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/09/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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