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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201395
Report Date: 11/03/2021
Date Signed: 11/03/2021 06:08:55 PM

Document Has Been Signed on 11/03/2021 06:08 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:CNS ALTA PEAKFACILITY NUMBER:
157201395
ADMINISTRATOR:GRIGSBY, DIEDRAFACILITY TYPE:
735
ADDRESS:7510 ALTA PEAKTELEPHONE:
(661) 665-9980
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 5CENSUS: 0DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Regional Residential Manager Vanessa Cortes;TIME COMPLETED:
06:15 PM
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An Annual Inspection Control visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Regional Residential Manager (RRM) Vanessa Cortes & stated purpose of visit.

One central entry point has been designated for universal entry screening. Routine symptom screening including temperature taken & recorded daily for all staff, residents, & visitors.
Infection Control signs are posted, including in bathrooms with hand washing techniques. Soap & paper towels available. Hand sanitizer available on entry & throughout the facility. Face coverings in use & available. Sufficient supply of PPEs. Infection control policies & procedures & practices in place & currently applied.

No deficiencies issued.
Exit interview conducted with RRM. Report Provided.


Continued.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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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: CNS ALTA PEAK
FACILITY NUMBER: 157201395
VISIT DATE: 11/03/2021
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Continued from Page 1.

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 Residential Facility (ARF):


· LIC 308 Designation of Facility Responsibility;
· LIC 309 Administrative Organization;
· LIC 500 Personnel Report;
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities;
· LIC 9020 Register of Facility Clients/Residents Please include date of birth (DOB) & Admission Date (Admin Date);
· Copy of current Administrator Certificate(s);
· Alternate contact information including name(s), telephone number(s), & email address(es);

Please submit the above forms/information to Fresno CCL by: November 21, 2021.

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
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