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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208968
Report Date: 09/14/2024
Date Signed: 09/14/2024 12:39:52 PM

Document Has Been Signed on 09/14/2024 12:39 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/
DIRECTOR:		LEYVA, MARYCRUZFACILITY TYPE:
735
ADDRESS:9055 ROAD 238TELEPHONE:
(559) 310-5703
CITY:TERRA BELLASTATE: CAZIP CODE:
93270
CAPACITY: 6CENSUS: 4DATE:
09/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Marycruz LeyvaTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On 9/14/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection on this date. LPA introduced self and stated purpose. LPA met with Licensee/Administrator Marycruz Leyva to conduct visit.

All residents were present during today's inspection. Residents observed to be interacting with staff at time of inspection.

Facility toured inside and outside. Facility observed to be clean, odor free, and at a comfortable temperature. LPA toured residents bedroom and observed all required furnishings. All linen observed to be clean and no good repair. Resident bathrooms, water temperature measured 107 degrees F. All common areas in the facility have adequate seating available for residents. Kitchen toured, LPA observed an adequate food supply for the residents in care. Knives observed to be locked and secured in medication cabinet. Medication observed to have original labels and to be administered as prescribed.

Fire extinguisher present with a service date of 1/8/24. Facility is equipped with a pull station and fire sprinkler system. The last fire drill was conducted on 7/6/2024 according to facility records.

Outside of facility toured. Perimeter of facility is secured with fencing. All exits open free of obstruction. No hazards observed.

LPA received updated LIC 9020 and LIC 500 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: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2024
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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