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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209130
Report Date: 03/22/2022
Date Signed: 03/22/2022 01:14:42 PM

Document Has Been Signed on 03/22/2022 01:14 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:
547209130
ADMINISTRATOR:LEYVA, KRISTYNFACILITY TYPE:
735
ADDRESS:2230 W. PUTNAM COURTTELEPHONE:
(559) 310-7357
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Kristyn LeyvaTIME COMPLETED:
01:24 PM
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On this date, 3/22/2022 LPA was met by Licensee, Kristyn Leyva and stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point used by staff and all visitors.

Facility observed clean with no obstruction or fire clearance issues. Hand sanitizer was readily available throughout the facility for residents, staff and visitors. Four (4) resident bedrooms are private, resident bedroom with two occupants have a minimum of 6 feet between beds.

Fire extinguisher present and has a service date of 1/12/22. Smoke detectors and carbon monoxide detectors present and observed operational during today's inspection.

LPA observed 7-day supply of non-perishable and a 2-day supply of perishable food available. All chemicals and PPE are secured in locked garage. Mitigation submitted to Department October 2021, a copy provided via e-mail to LPA during inspection visit. Kristyn Leyva also serves as facility Administrator certification #6042519735, expires 1/08/2024. CPR/First Aid expires 4/27/23.

LPA provided with Administrator Certificate, CPR card, staff schedule, LIC 610, and LIC 9020 during facility inspection.

No deficiencies were observed during today's inspection. Exit interview was conducted. Facility report signed on site. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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