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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208964
Report Date: 05/19/2022
Date Signed: 05/19/2022 06:41:46 PM

Document Has Been Signed on 05/19/2022 06:41 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:CROMWELL CARE HOMEFACILITY NUMBER:
107208964
ADMINISTRATOR:BABAKHANI, ARDALAN ALEXFACILITY TYPE:
740
ADDRESS:2124 CROMWELL AVETELEPHONE:
(559) 940-7373
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Administrator Pacita Baltazar TIME COMPLETED:
06:45 PM
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On 05/19/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Theresa Sy, Caregiver. Administrator Pacita Baltazar was called and arrived shortly and conduct tour with LPA. All four residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings.

LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 07/25/21. LPA Cleaning supplies were stored and locked in laundry room. LPA observed 30-day PPE supplies in facility.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed four bedroom that are single occupant. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. LPA observed hand washing posting by bathroom sinks. The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 5/25/22. The following updated forms were requested: Lic 400 and Lic 402. LPA received copy of current facility sketch, Administrator certificate, Lic 308, Lic 309, Lic 500, Lic 610E, Lic 9020, and current liability insurance. A copy of this report was provided to the Administrator.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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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