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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208968
Report Date: 10/17/2023
Date Signed: 10/17/2023 01:05:16 PM

Document Has Been Signed on 10/17/2023 01:05 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:LEYVA FAMILY HOME LLCFACILITY NUMBER:
547208968
ADMINISTRATOR:LEYVA, MARYCRUZFACILITY TYPE:
735
ADDRESS:9055 ROAD 238TELEPHONE:
(559) 310-5703
CITY:TERRA BELLASTATE: CAZIP CODE:
93270
CAPACITY: 6CENSUS: 4DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marycruz LeyvaTIME COMPLETED:
01:05 PM
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On 10/17/23, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection on this date. LPA introduced self and stated purpose, LPA allowed entrance by Direct Care staff. Licensee Marycruz Leyva contacted by telephone and arrived a short time later to conduct visit. Marycruz Leyva also serves as facility Administrator Certificate #6050346735, expires 12/06/2024.

Three residents were present at time of inspection, residents have in home day program M-F 8:30am - 1:00 pm.

Facility toured inside and outside. Facility observed to be clean, odor free, and at a comfortable temperature. All resident bedrooms have the required furnishings. Linen observed to be clean and in good repair. Additional linen supply available. Resident bathroom toured. All bathrooms fixtures observed to be in good repair and working. Hot water measured 107 degrees F. All common areas have adequate seating and lighting available for all residents. Medications observed to be stored and secured in kitchen cabinet. Medications reviewed to and observed to have original labels and be administered as prescribed.

The fire extinguisher was serviced on 01/16/2023. Carbon monoxide detectors tested and appeared operational during inspection during today's inspection. Facility is equipped with a pull station and fire sprinkler system. The last fire drill was conducted on 9/30/2023 according to facility records.

LPA received updated LIC 9020, LIC 500, LIC610 during facility visit. Resident and staff files reviewed during inspection.

No deficiencies observed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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