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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208964
Report Date: 07/18/2024
Date Signed: 07/18/2024 11:55:38 AM

Document Has Been Signed on 07/18/2024 11:55 AM - 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/
DIRECTOR:		BABAKHANI, ARDALAN ALEXFACILITY TYPE:
740
ADDRESS:2124 CROMWELL AVETELEPHONE:
(559) 940-7373
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:39 AM
MET WITH:Pacita Baltazar
Ardalan Alex Babakhani		TIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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On 7/18/2024, Licensing Program Analysts (LPAs) M. Medina and D. Boyd conducted an unannounced Annual Required inspection. LPAs arrived, introduced themselves, and stated purpose of visit. LPA's allowed entrance by direct care staff, Licensee and Administrator contacted by telephone and arrived a short time later to conduct facility inspection.

Currently, four (4) residents in care. One resident was present at time of LPA arrival, who shortly left for day program. Residents attend day program Monday - Friday 8:00 AM - 2:00 PM.

Facility toured inside and outside. Facility observed to be clean, odor free, and a comfortable temperature. Resident bedrooms toured and observed to have all required furnishings. Resident bathrooms toured, LPA observed grab bars, shower mats, and shower chair available. Water temperature measured at 113 degrees F. All common areas observed to have adequate seating available for residents in care. Kitchen toured, facility observed to have a 2-day supply of perishable and a 7-day supply of non-perishable food available. All knives observed to be locked and secured. Medication observed to be locked and observed. Medication observed to have original labels and to be administered as prescribed.

Carbon monoxide detector and smoke detectors observed operational at time of inspection. Fire extinguisher present with a purchase date of 4/11/24. Last fire drill conducted 5/27/2024 according to facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CROMWELL CARE HOME
FACILITY NUMBER: 107208964
VISIT DATE: 07/18/2024
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Outside of facility toured. Exit gate is self latching. All exits open free of obstruction. Storage shed in back yard observed to be locked and secured. No hazards observed.

Administrator to submit updated LIC 9020 and Copy of Liability Insurance to Fresno Regional Office no later than 7/26/2024.

No deficiencies cited.

Exit interview conducted. A copy of this signed report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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