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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208793
Report Date: 09/23/2022
Date Signed: 09/25/2022 08:21:49 PM

Document Has Been Signed on 09/25/2022 08:21 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:BAXTER-LEYVA ADULT FACILITY, LLCFACILITY NUMBER:
547208793
ADMINISTRATOR:LEYVA, KRISTYNFACILITY TYPE:
735
ADDRESS:711 SANDRA LANETELEPHONE:
(559) 615-1697
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 4DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Kristyn LeyvaTIME COMPLETED:
03:23 PM
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On 9/23/22, Licensing Program Analyst (LPA) M. Medina arrived unannounced to conduct an Annual Required Inspection. LPA Medina observed all COVID-19 safety measures in place upon entry. Staff observed to be wearing masks, sign-in, temperature checks, masks and sanitizer available at entry.

Facility observed to be clean and odor free. No fire hazards observed. All common areas have adequate seating available for residents. Bathrooms observed to have trash cans with lids. All residents have private bedrooms, with all required furnishings. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable available for residents.

Water temperature measured at 112 degrees F. Fire extinguisher has a service date of 1/12/22. Carbon monoxide detectors and smoke detectors observed to be operational during inspection.

LPA received copies of Infection Control Plan for Monkey Pox, Administrator Certificate, CPR card, Fire Drill Record, LIC 9020, Staff Schedule and LIC 610.

No deficiencies were observed. Exit interview was conducted. Report signed during inspection and a copy left for facility file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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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