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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206674
Report Date: 11/04/2022
Date Signed: 11/04/2022 09:50:07 AM

Document Has Been Signed on 11/04/2022 09:50 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:AIMES NOBLE IIFACILITY NUMBER:
157206674
ADMINISTRATOR:CORTEZ, JOSEFACILITY TYPE:
740
ADDRESS:5729 NOBLE STREETTELEPHONE:
(661) 589-9992
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 4CENSUS: 2DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Administrator, Jose CortezTIME COMPLETED:
10:03 AM
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On 11/04/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. Facility staff contacted Administrator, Jose Cortez (AD), who arrived a short time later. Upon entry to the facility, LPA observed a visitor temperature check / sign in. The facility has one central entrance and exit.

LPA conducted a facility tour with AD. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing signs observed in the resident bathrooms. Other various Covid-19 related signs were not observed in the common areas. Per AD, the facility was recently painted and all signs were taken down.

LPA observed a two day supply of perishable foods and seven day supply of non-perishable foods. Cleaning supplies were observed behind a locked cabinet in the laundry room. LPA observed an adequate supply of PPE and cleaning supplies. LPA observed facility staff not to not be wearing facial coverings. Resident’s files have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/18/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

No deficiencies issued. An exit interview was conducted with AD. A copy of this report was discussed and provided to Administrator, Jose Cortez, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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