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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209181
Report Date: 10/19/2021
Date Signed: 10/19/2021 01:06:40 PM

Document Has Been Signed on 10/19/2021 01:06 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 HAVENFACILITY NUMBER:
107209181
ADMINISTRATOR:SANDONE, RONALD J.FACILITY TYPE:
740
ADDRESS:5787 W. CROMWELL AVE.TELEPHONE:
(925) 470-9712
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 0DATE:
10/19/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Percival TobiasTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct the Pre-Licensing Inspection. LPA met with Ronald Sandone and Percival Tobias.

LPA began the tour by entering through the front door of the home. An Emergency Evacuation Plan, Disaster Plan and required postings were observed upon entry. LPA observed Covid-19 Health Screening area including hand sanitizer and visitor sign in.

Furniture in common rooms observed to be in good repair with adequate lighting throughout. Resident bedrooms have the required furnishings, lighting and bed linens including mattress covers. Smoke and Carbon Monoxide detectors present and in working order. LPA observed a supply of extra bed linens, towels, and personal hygiene/grooming products. Hot water temperature in bathrooms measured at 117 degrees F. Soap and paper towels were placed in bathrooms along with trash cans and hand washing signs posted..

Kitchen observed to have supply of dishes, cups, plates, utensils, pots and pans and cooking utensils in good repair. LPA observed a 7 day of non-perishable food. Counter tops and cabinets are clear and appropriate for food storage and preparation. Knives are kept in a locked drawer.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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 HAVEN
FACILITY NUMBER: 107209181
VISIT DATE: 10/19/2021
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Cleaning supplies and chemicals are stored in the locked laundry room and separate from any food items. A Washer and Dryer were observed in the laundry room with additional shelving for storage. Appliances observed to be in working order and at proper temperature.

A locked storage closet for medications, First Aid Kit, Personnel and Resident files was observed and located in the hallway. First aid kit contains all required items. A fire extinguisher is present in the kitchen. Doors and passageways are unobstructed throughout the home.

Outside of the facility toured. The home does not have a pool, no bodies of water or other hazards were observed. Outdoor activity space with shaded areas and seating were located on the backyard patio. LPA observed a self-releasing gate and windows have screens in good repair.

Component III was conducted during pre-licensing visit with the Administrator.

LPA called the designated facility phone (559) 353-2603 during the visit. The phone is set up and in working order.

The applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

An exit interview was conducted with the Administrator. A copy of this report was provided to Licensee.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC809 (FAS) - (06/04)
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