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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208925
Report Date: 03/24/2023
Date Signed: 04/10/2023 04:47:42 PM

Document Has Been Signed on 04/10/2023 04:47 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:NOBLE SERVANT HOMESFACILITY NUMBER:
107208925
ADMINISTRATOR:SOCIAS, KRISTINA FAITHFACILITY TYPE:
740
ADDRESS:4140 W. CAPITOLA AVETELEPHONE:
(559) 492-7005
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 3DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Kristina SociasTIME COMPLETED:
02:04 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection.
LPA met with and explained the purpose of the visit with Licensee/Administrator (AD) Kristina Socias.

During this visit, LPA toured the facility. Furniture and flooring in common rooms observed to be in good repair with adequate lighting throughout. Resident bedrooms have required furnishings, lighting and linens. The kitchen observed clean, in good repair with necessary items and appliances. LPA observed required food supply, paper products and PPE. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored and locked. First aid kit contained required items. Facility has designated visitation areas available inside and out. Outside of the facility toured. LPA observed a self-releasing gate and windows have screens in good repair. Doors and passageways are unobstructed throughout the home and outside. Fire Extinguishers dated 9/2022. Smoke and Carbon Monoxide detectors present and in working order. Emergency & Disaster Plan and Infection Control Procedures reviewed. Administrator Certification expires 6/28/2024.

LPA conducted resident and staff file reviews and interviews.

No deficiencies were cited during this inspection. An exit interview was conducted.

A copy of this report was left with AD whose signature confirms receipt of these documents.


LPA requested the following updated forms by 4/3/23: Designation of Facility Responsibility (LIC 308), Personnel Report (LIC 500), Emergency Disaster Plan (610E), Client Roster (LIC 9020), Current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023
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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