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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202355
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:05:12 AM


Document Has Been Signed on 12/15/2022 11:05 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: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: 4DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Myat TusawTIME COMPLETED:
11:22 AM
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On 12/15/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection - infection control. LPA introduced self, stated the purpose of the visit and was granted entry to the facility by Administrator, Myat Tusaw. Facility has one central entrance and exit. Visitor log-in/temperature check, masks, and disinfection station was observed upon entry.

Facility tour conducted with Administrator. Facility appeared clean. 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. Resident bedrooms were checked, 2 rooms are single occupant and 1 bedroom is shared with beds at least 6 feet apart. LPA observed a nightstand blocking the exit in the shared bedroom.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. LPA observed an adequate supply of PPE and cleaning supplies. LPA observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL Office by 01/03/2022: Current Copy of Administrator’s Certificate, LIC308, LIC309, LIC400 (if applicable), LIC 500, LIC402 (If applicable), and Plan LIC610D Emergency and Disaster

A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 for fire clearance on the attached 809D.

Exit interview conducted and a Plan of Correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Myat Tusaw, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/15/2022 11:05 AM - It Cannot Be Edited

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: TEDENEK ELDER HOME
FACILITY NUMBER: 157202355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in when a nightstand was observed blocking an exit in the shared bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Administrator repositioned the nightstand during the inspection. POC CLEARED during inspection
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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