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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209248
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:39:19 PM

Document Has Been Signed on 10/17/2023 03:39 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 II, INCFACILITY NUMBER:
547209248
ADMINISTRATOR:LEYVA, MARYCRUZFACILITY TYPE:
735
ADDRESS:9035A ROAD 238TELEPHONE:
(559) 310-5703
CITY:TERRA BELLASTATE: CAZIP CODE:
93270
CAPACITY: 6CENSUS: 4DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Marycruz Leyva
Stephanie Ambriz		TIME COMPLETED:
03:42 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 of visit. LPA conducted facility tour with Licensee Marycruz Leyva. Marycruz Leyva also serves as facility Administrator Certificate #6050346735, expires 12/06/2024.

All residents were present during today's inspection.

Facility toured inside and outside. Facility observed to be clean, odor free, and at a comfortable temperature. All residents have private bedrooms, all bedrooms observed to have required furnishings. Linen observed to be clean and in good repair. Resident bathroom toured, bathroom fixtures observed to be in good repair and working. Hot water measured 106 degrees F. All common areas have adequate seating and lighting available for all residents. Medications observed to be stored and secured in medication room.

The fire extinguisher was serviced on 01/16/2023. Facility is equipped with a pull station and fire sprinkler system. The last fire drill was conducted on 9/29/2023 according to facility records.

LPA received updated LIC 9020, LIC 500, LIC610 during facility visit. Resident 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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