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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209288
Report Date: 03/03/2023
Date Signed: 03/07/2023 03:43:21 PM

Document Has Been Signed on 03/07/2023 03:43 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CAMILA CARE VILLA, LLCFACILITY NUMBER:
157209288
ADMINISTRATOR:PANGILINAN, MARIA EMMAFACILITY TYPE:
740
ADDRESS:10005 COBBLESTONE AVETELEPHONE:
(904) 762-5945
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 5DATE:
03/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Maria Emma Pangilinan, LicenseeTIME COMPLETED:
12:30 PM
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On 03/03/23, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing and Component III inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Maria Emma Pangilinan, Licensee.

The facility is 5 bedroom and 3-bathroom home. Fire clearance was granted for 5 Non-Ambulatory and 1 bedridden for total of 6 capacity. All five residents were present during this inspection. LPA toured the facility with Licensee. Facility temperature is set to 70 degrees F. Common areas were furnished and had adequate seating and lighting available. A fire extinguisher was observed and has a service date of 12/18/22. Medications were kept locked and inaccessible to residents in care in kitchen shelves. Kitchen was toured and observed to have dishes, plate, and utensils. Refrigerator temperature maintained at 35.5 degrees F and freezer temperature at 0-degree F. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods. Knives were observed to be locked and secured in kitchen shelf. Cleaning supplies and chemicals were observed to be in a locked cabinet in laundry room.

LPA observed an extra supply of bed linens and personal hygiene products. Bedrooms were observed to have required furnishings. All bathrooms are observed with securely fastened grab bars and non-skid mat. Bathroom toured. Hot water measured at 110.5 degrees F in bathroom 1 and 109.3 to 109.7 degrees F in the bathroom in the shared bedroom. Outside of facility toured. Exterior toured and LPA observed side gate to be self-closing and free of debris.First aid kit was observed and contained all required items. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. Resident records were reviewed. LPA observed resident Admission Agreements, Physician Reports, and Pre-Appraisal. Staff records were reviewed. All personnel records observed to have a criminal record clearance.

Component III was conducted during today's pre-licensing visit.

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

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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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