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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208968
Report Date: 09/23/2022
Date Signed: 09/23/2022 10:34:20 AM

Document Has Been Signed on 09/23/2022 10:34 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:LEYVA FAMILY HOME LLCFACILITY NUMBER:
547208968
ADMINISTRATOR:LEYVA, MARYCRUZFACILITY TYPE:
735
ADDRESS:9055 ROAD 238TELEPHONE:
(559) 535-0233
CITY:TERRA BELLASTATE: CAZIP CODE:
93270
CAPACITY: 6CENSUS: 4DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH: Marycruz Leyva, Licensee TIME COMPLETED:
10:45 AM
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On 09/23/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with caregiver Sydney Dowling. LPA conducted a facility tour with caregiver. A Licensee Marycruz Leyva was called and shortly. There are currently three clients present during tour.

Upon entry facility staffs was observed with facial mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed Covid-19 signs and cough etiquette postings in facility. All clients’ records reviewed to have updated emergency contact information. Staff records were reviewed for good health and infection control training.

LPA checked clients’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in the laundry room. LPA observed fire extinguisher served date: 01/17/2022.

All clients’ room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. The exterior tour was conducted. Side gate was self-closing and free of debris.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 09/29/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610D, and control of property. Administrator was informed that as COVID-19 precautionary measure, this report was provided to the Administrator via email.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
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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