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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200632
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:35:32 AM

Document Has Been Signed on 11/15/2022 11:35 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:SVS BAKERSFIELD SOUTHWEST ADULT DAY PROGRAMFACILITY NUMBER:
157200632
ADMINISTRATOR:VELAZQUEZ, BLANCAFACILITY TYPE:
775
ADDRESS:4705 NEW HORIZON BLVD, STE 12TELEPHONE:
(661) 241-6760
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 90CENSUS: 33DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Latisha Albritton, Regional ManagerTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA met with Regional Manager Latisha Albritton. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to clients and visitors. Social distancing is maintained in the common and activity areas. The exterior tour was conducted. LPA checked three program vans.

Cleaning and PPE supplies were checked. Facility records were reviewed for infection control training. Facility staff was observed with mask on. Facility does not provide meals. Cleaning and PPE supplies were checked. Clients will wear masks during programming. Client’s files have updated emergency contact information.

Exit interview was conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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: SVS BAKERSFIELD SOUTHWEST ADULT DAY PROGRAM
FACILITY NUMBER: 157200632
VISIT DATE: 11/15/2022
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Day Program (ADP):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 11/22/2022.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC809 (FAS) - (06/04)
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