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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209363
Report Date: 10/16/2023
Date Signed: 10/16/2023 12:01:14 PM

Document Has Been Signed on 10/16/2023 12:01 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
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: 4DATE:
10/16/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Leticia JacksonTIME COMPLETED:
12:15 PM
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On 10/16/23, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing and
Component III inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the
facility. LPA met with Licensee Leticia Jackson. LPA toured facility with Licensee.

The facility is 4 bedroom and 2-bathroom home. Fire clearance was granted for 6 non-Ambulatory for total of 6 capacity. LPA toured the facility with Licensee. All four residents were present during this inspection. LPA observed 2 bedridden residents in bedroom 1 and bedroom 3.

The facility was observed to be at a comfortable temperature of 76 degrees F, furnished with adequate seating. A fire extinguisher was observed and has a service date of 01/11/2023. Medications were kept locked in kitchen shelf. Kitchen was toured and observed to have dishes, plate, and utensils. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -4 degrees F and refrigerator temperature was maintained at 40 degrees F. Knives were observed to be locked and secured in kitchen shelf. Cleaning chemicals was observed stored and locked in under kitchen counter. LPA observed an extra supply of bed linens and personal hygiene products. Bedrooms were observed to have required furnishings. All bathrooms toured and operational during inspection. LPA observed bathroom with securely fastened grab bars and non-skid mat. Hot water measured at 111.8 degrees F in bathroom 1 and 105.9 degrees F in the master bathroom. Washer and dryer observed operational during inspection. Outside of facility toured. LPA observed side gate to be self-closing. Carbon monoxide and smoke detectors were tested and observed to be operational. First aid kit observed to have all required items. All resident records were reviewed. LPA observed resident Admission Agreements, Physician Reports, and Pre-Appraisal. Staff records were reviewed. Personnel records observed to have a criminal record clearance.

LPA have founded the facility have not met all the Pre-Licensing requirements.

Component III was conducted during today's pre-licensing visit. An exit interview was conducted. A copy of this report was provided to Licensee, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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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