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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206953
Report Date: 08/17/2022
Date Signed: 08/17/2022 03:23:58 PM

Document Has Been Signed on 08/17/2022 03:23 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:BLUEBERRY HILLFACILITY NUMBER:
107206953
ADMINISTRATOR:CASTIGADOR, YOLANDAFACILITY TYPE:
740
ADDRESS:7447 N RIVERSIDE DRIVETELEPHONE:
(559) 981-5630
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 6DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Grace PetilTIME COMPLETED:
03:32 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Infection Control Inspection. LPA met with and explained the purpose of the visit with facility Designee Grace Petil.

LPA toured the facility inside and out. Infection control procedures which were observed and/or reviewed by LPA include: Daily symptom screenings for residents, staff and visitors, testing & vaccination requirements, Isolation room procedures, PPE and daily infection control procedures. Sanitizer is available throughout the home and bathrooms are stocked with soap and paper towels. Hand washing and other symptom related signs are posted. LPA observed supply of PPE, medications, paper goods and disinfecting products.

Administrator has agreed to revise daily screening logs for residents, staff and visitors. Additional PPE will be purchased to increase supply.






No citations were issued during this inspection. A copy of this report was provided, and an exit interview was conducted with Grace Petil.

LPA requested the following updated forms by 8/26/22: LIC 308, LIC 309, LIC 500, LIC 610E, LIC9020, Current Liability Insurance
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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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