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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209363
Report Date: 12/13/2023
Date Signed: 12/13/2023 10:48:36 AM


Document Has Been Signed on 12/13/2023 10:48 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:DEVOTED HEARTS SENIOR CARE HOME LLCFACILITY NUMBER:
157209363
ADMINISTRATOR:JACKSON, LETICIAFACILITY TYPE:
740
ADDRESS:10311 RIO DEL MAR DRIVETELEPHONE:
(661) 735-7308
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 6DATE:
12/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Licensee Leticia JacksonTIME COMPLETED:
11:00 AM
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
On 12/13/23, Licensing Program Analyst (LPA) M. Yang arrived announced to conduct a follow-up Pre-licensing inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the
facility. LPA met with Licensee Leticia Jackson.

On 12/01/2023, Licensee informed the department currently there are 5 non-ambulatory and 1 bedridden residing in the facility. The department was informed 1 bedridden resident was relocated prior to Fire inspection on completed on 11/21/23. Resident in bedroom 1 is non ambulatory and resident in bedroom 3 is bedridden. LPA observed a total of 2 non ambulatory, 1 bedridden, and 3 ambulatory residents.

Fire clearance granted for 5 non-ambulatory and 1 bedridden for total of 6 capacity.

Facility is in compliance and no follow up visit is needed. Facility is ready to be licensed.

I have found that applicant has met all pre licensing requirements. LPA will submit documentation to CAB in


Sacramento for final review prior to license being issued.

An exit interview was conducted. A copy of this report was provided to Licensee, whose signature confirms receipt of this report.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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