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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209248
Report Date: 09/14/2024
Date Signed: 09/14/2024 03:22:13 PM

Document Has Been Signed on 09/14/2024 03:22 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/
DIRECTOR:		LEYVA, MARYCRUZFACILITY TYPE:
735
ADDRESS:9035A ROAD 238TELEPHONE:
(559) 310-5703
CITY:TERRA BELLASTATE: CAZIP CODE:
93270
CAPACITY: 6CENSUS: 3DATE:
09/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Marycruz LeyvaTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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On 9/14/24, Licensing Program Analyst (LPA) M Medina conducted an unannounced Annual Required Inspection. LPA arrived, introduced self and stated purpose of visit. LPA met with Licensee Marycruz Leyva to conduct inspection. Marycruz Leyva also serves as facility Administrator certificate #6050346735, expires 12/06/2024.

Facility toured. Inside of facility observed to be clean, odor free, and well lit. All common areas observed to have adequate seating available. Resident bedrooms, observed to be clean, beds had adequate linen, and all required furnishings. Bathroom toured, fixtures observed to be operational during inspection. Water temperature measured at 105 degrees F. Kitchen toured, LPA observed a 2-day supply of perishable and 7-day supply of non-perishable available .Knives are locked and secured in kitchen drawer. Medications are locked and secured in medication room. Medications observed to have original labels and be administered as prescribed. All cleaning supplies are locked and secured in laundry room

Fire extinguisher present with a service date of 7/6/24. Facility equipped with pull station. Carbon monoxide detector present and observed operational during facility inspection. Last fire drill conducted on 8/23/2024 according to facility records.

Outside of facility toured. All exits open free of obstruction. No hazards observed.

LPA received copies of LIC 500 and LIC 9020 during facility inspection.

Staff and resident files reviewed.

No deficiencies cited during inspection. Exit interview conducted and a copy of report provided for facility records.
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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