547209130-4-7-2026-24-AS-BMIA-DSWQSK-20260407122540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547209130
Report Date: 04/07/2026
Date Signed: 04/07/2026 12:26:00 PM

Document Has Been Signed on 04/07/2026 12:26 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	BAXTER-LEYVA ADULT FACILITY, LLC		FACILITY NUMBER:	547209130
ADMINISTRATOR/ DIRECTOR:	LEYVA, KRISTYN		FACILITY TYPE:	735
ADDRESS:	2230 W. PUTNAM COURT		TELEPHONE:	(559) 310-7357
CITY:	PORTERVILLE	STATE: CA	ZIP CODE:	93257
CAPACITY: 6		CENSUS: 5	DATE:	04/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:58 AM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) B. Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA introduced themselves and was allowed entrance into the facility. LPA met with Administrator Kristyn Leyva. Facility is licensed for 6 residents and has a current census of 5. Water temperature was checked in the kitchen which read at 107.9 degrees Fahrenheit. Fire Extinguisher was serviced January 12, 2026, and is within the safety regulation period. Smoke and carbon monoxide detectors were tested and in working order. Kristyn Leyva Administrator's Certification expires January 8, 2028. Staff files were reviewed, are completed, and current. Resident files were reviewed, completed, and current. Facility provided a log for disaster drills that are conducted quarterly. First aid kit on site and complete. Toxins and cleaning supplies are locked and inaccessible. There is a locked storage for medications. LPA reviewed R1’s medication. Centrally stored medication log is not completed and the MARS do not have the necessary information. R1’s physician report indicated R1 is not able to communicate their needs. Medications are not being completed logged with start dates and expiration dates. Docusate 100MG CAP & Hydroxyzine HCL 10mg TAB were not logged on the PRN log. LPA observed stains in R2’s carpet, windowsills have insect and debris, R3 bed is worn, common bathroom shower curtain needs to be cleaned (inside), and kitchen cabinet with lids needs to be wiped down from debris.

NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 04/07/2026 12:26 PM - It Cannot Be Edited

Created By: Brianna Miranda On 04/07/2026 at 11:56 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BAXTER-LEYVA ADULT FACILITY, LLC	FACILITY NUMBER: 547209130
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(k)(7)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, & record review, the licensee did not comply with the section cited above in 1 count out of 1 total count R1's centrally stored log was not complete with required information, Administrator stated the centrally stored logs are not updated, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2026
	Plan of Correction
1 2 3 4	Administrator will provide a statement to the Dept by POC due date indicating when Centrally stored logs will be completed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:

	Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2026 12:26 PM - It Cannot Be Edited

Created By: Brianna Miranda On 04/07/2026 at 11:56 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BAXTER-LEYVA ADULT FACILITY, LLC	FACILITY NUMBER: 547209130
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in windowsills have debris, R2's rug entering the room needing to be cleaned, kitchen shelf needing to be cleaned, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2026
	Plan of Correction
1 2 3 4	Administrator will make corrections and provide pictures to the Dept by POC due date.

Type B

Section Cited

CCR

85088(c)(1)

Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 count out of 5 total count a resident's bed is worn and my need to be replaced, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2026
	Plan of Correction
1 2 3 4	Administrator will make corrections and provide pictures to the Dept by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:

	Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BAXTER-LEYVA ADULT FACILITY, LLC	FACILITY NUMBER: 547209130
	VISIT DATE: 04/07/2026

NARRATIVE

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LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms, bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms kept according to residents’ preference, properly furnished, and with adequate lighting. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Deficiencies observed were cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. The documents listed shall be sent to Licensing by April 17, 2026.

Exit interview conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Kristyn Leyva.

NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC809 (FAS) - (06/04)

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