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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200335
Report Date: 10/13/2021
Date Signed: 10/13/2021 01:18:16 PM

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: 0DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Licensee Harold and Jamesie GridironTIME COMPLETED:
01:30 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Licensee Harold and Jamesie Gridiron and discussed the purpose of the visit. LPA and Licensee Jamesie Gridiron began the tour at the front entrance/office of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed locked in a closet. LPA observed the following personal protective equipment in front entry and storage room; gowns, face shield, gloves, and masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks. Facility currently does not have any residents.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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