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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209181
Report Date: 12/11/2023
Date Signed: 12/11/2023 02:21:57 PM

Document Has Been Signed on 12/11/2023 02:21 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:YOLANDA CASTIGADORFACILITY TYPE:
740
ADDRESS:5787 W. CROMWELL AVE.TELEPHONE:
(925) 470-9712
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 4DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Yolanda CastigadorTIME COMPLETED:
02:28 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 Administrator (AD) Yolanda Castigador and Licensee (Lic) Ron Sandone.

During this visit, LPA toured the facility inside & out. Resident bedrooms contained required furnishings and lighting. LPA observed required items in bathrooms which were clean with hot water temperature reading of 110 degrees. Resident hygiene supplies were properly stored and available. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. 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. Smoke and Carbon Monoxide detectors present and in working order. Fire extinguisher date 6/20/23. LPA conducted resident and staff file reviews including medication audit and interviews.

A deficiency is being cited in accordance with California Code of Regulations on the attached Lic809-D.
The facility does not have a current Infection Control Plan.

LPA requested the following updated forms faxed to CCLD by 12/18/23: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan LIC610E, Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and emailed to AD.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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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Document Has Been Signed on 12/11/2023 02:21 PM - It Cannot Be Edited


Created By: Katie Brown On 12/11/2023 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CROMWELL HAVEN
FACILITY NUMBER: 107209181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Administrator has agreed to develop and submit a complete Infection Control Plan. Additionally, proof of training will be submitted to CCLD by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
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