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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209248
Report Date: 10/04/2022
Date Signed: 10/04/2022 12:16:04 PM

Document Has Been Signed on 10/04/2022 12:16 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:LEYVA FAMILY HOME II, INCFACILITY NUMBER:
547209248
ADMINISTRATOR:LEYVA, MARYCRUZFACILITY TYPE:
735
ADDRESS:9035A ROAD 238TELEPHONE:
(559) 310-5703
CITY:TERRA BELLASTATE: CAZIP CODE:
93270
CAPACITY: 4CENSUS: 4DATE:
10/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marycruz Leyva, Administrator TIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) K.Kaur conducted a Pre-licensing Inspection on this date. LPA met with Licensee/Administrator Marycruz Leyva. A tour of the facility was conducted together. Inspection is for a Change of Ownership with 4 residents present.

The facility has 3 bedrooms designated for residents. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas were properly furnished and well-lit throughout. Fire extinguisher was observed with a service date of 1/17/2022. Smoke detectors and carbon monoxide detector were tested and observed to be operational. The First Aid Kit was observed to have the required supplies. Medication will be kept locked in in a separate closet with locked cabinets. Knives, cleaning supplies and chemicals will be locked in the medication closet until a built-in locked cabinet or locks can be installed in the kitchen.

The tour started in the Kitchen and proceeded to living area and resident's bedrooms. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Bathroom was properly equipped and has trash cans with a fitting lid. Hot water was tested and was 112.6 F in the bathroom. LPA observed clients Admission Agreements and Physician Reports. Outside toured and observed free of obstructions. Facility has adequate seating in the front yard under shaded area. Facility phone number will be (559) 535-5388. Staff records have a criminal record clearance and first aid.

Required postings were observed. Component III was also conducted and completed.

Exit interview was conducted, report was signed on site and a printed copy of the report was provided to the
Licensee. Pre-licensing requirements were met.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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