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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150403850
Report Date: 03/28/2022
Date Signed: 03/28/2022 03:49:45 PM


Document Has Been Signed on 03/28/2022 03:49 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:DE VILLA REHABILITATION FACILITYFACILITY NUMBER:
150403850
ADMINISTRATOR:VAN HORN, ALICIAFACILITY TYPE:
735
ADDRESS:1709 "D" STREETTELEPHONE:
(661) 323-1778
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY:24CENSUS: 15DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Alicia Van HornTIME COMPLETED:
12:00 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Administrator Alicia Van Horn and discussed the purpose of the visit. LPA and Administrator Alicia Van Horn began the tour at the front entrance/office of the facility. Facility does not have a LIC808 Mitigation Plan. Administrator agrees to submit a plan by 4/11/22. Facility does have Covid 19 safety practices in place.

Temperature check and disinfection station was observed upon entry. Facility needs to have a visitation log. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed to be locked in a closet. LPA observed the following personal protective equipment to be locked in storage room; face shield, gloves, gowns, and masks.

Facility needs staff training for Covid 19 and covered trash cans will submit proof by 4/11/22.

Resident’s files have updated emergency contact information.


Exit interview was conducted and a copy of this report was provided via email.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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