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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202355
Report Date: 12/08/2021
Date Signed: 12/09/2021 08:23:48 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:TEDENEK ELDER HOMEFACILITY NUMBER:
157202355
ADMINISTRATOR:TUSAW, MYATFACILITY TYPE:
740
ADDRESS:13005 BIRKENFELD AVE.TELEPHONE:
(661) 588-0554
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 5DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator Mayat Tusaw TIME COMPLETED:
12:00 PM
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Licensing Program Analyst LPAs K.Kaur and Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Staff Thablay Wah who did temperature screening. Administrator Mayat Tusaw met with LPA's and conducted a facility tour.

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.

LPAs observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed in the laundry room in a locked cabinet. LPAs observed the following personal protective equipment in a storage cabinet; gowns, face shield, gloves, and masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

No deficiencies were observed.

Please submit the following forms/information to Fresno CCLD. Requested forms/ information: Current Copy of Administrator’s Certificate, LIC308, LIC309, LIC400 (if applicable), LIC 500, LIC402 (If applicable), and Plan LIC610D Emergency and Disaster. Exit interview was conducted and a copy of this report was provided via email.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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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