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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209223
Report Date: 05/16/2022
Date Signed: 05/17/2022 04:20:28 PM

Document Has Been Signed on 05/17/2022 04:20 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:PLEASANT HOME CAREFACILITY NUMBER:
157209223
ADMINISTRATOR:ASAWADILOKCHAI, YANINEEFACILITY TYPE:
740
ADDRESS:10609 PLEASANT VALLEY DRIVETELEPHONE:
(714) 655-6454
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 0DATE:
05/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Yaninee AsawadilokchaiTIME COMPLETED:
01:30 PM
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On 05/16/22, Licensing Program Analyst (LPA) L. Salazar arrived at the facility for an announced Pre-Licensing inspection. LPA was greeted by licensee and allowed entry. Upon entry, LPA observed the required facility postings to include disaster plan, personal rights, discrimination notice, theft and loss policy, facility sketch identifying the emergency exits and complaint poster. LPA observed an entry table for screening of COVID precautionary measures.

LPA toured the facility inside and out. The facility is a 4 bedroom, 2 bathroom house with a fire clearance for 6 non-ambulatory of which (1) may be bedridden. Any room may be approved for bedridden and a Hospice waiver was granted for (1). Bedrooms were furnished according to regulation. Bathrooms were observed to have grab bars and non-skid mats in the showers. Water temperature was tested and read 116 degrees F. Hand washing signs were observed in the bathroom.

Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available.


LPA observed and tested smoke and carbon monoxide detectors in the home. Both were functional. A supply of extra linen and towels were observed in the closet located in the hall near the bedrooms.

Kitchen was toured and observed to have dishes, plates, and utensils. Knives will be kept locked and secure in the kitchen pantry. Medications will be locked in a hall closet. First aid kit was observed and contained all required items.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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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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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223
VISIT DATE: 05/16/2022
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Cleaning supplies and chemicals observed to be locked in a cabinet located in the garage. Fire extinguisher was observed with a purchase date of 04/2022.

Bedrooms were observed to have the required furnishing and are ready for shared occupancy. Master bedroom will be designated for live-in staff. LPA observed an extra supply of bed linens.

Exits were open and free of obstructions. LPA observed side gate to be self-latching. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Component III was conducted during today's pre-licensing visit. Pre-licensing requirements have been met. Exit interview conducted.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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