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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200335
Report Date: 09/27/2021
Date Signed: 10/13/2021 10:24:00 AM

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:PASSION PLUS CARE HAVEN RES. CARE FAC.FOR ELDERLYFACILITY NUMBER:
157200335
ADMINISTRATOR:GRIDIRON, HAROLD & JAMESIEFACILITY TYPE:
740
ADDRESS:3025 LOTUS LANETELEPHONE:
(661) 831-0908
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY:6CENSUS: DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
09:00 AM
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On 09/27/2021, Licensing Program Analyst (LPA) Shawna Doucette arrived unannounced and attempted to conduct an Infection Control-Annual Inspection. LPA was unable to make contact at the facility. LPA left a voicemail for the facility to contact LPA via phone.

The department will return at a later date to conduct Annual Inspection.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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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