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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202355
Report Date: 12/07/2023
Date Signed: 12/07/2023 01:08:35 PM


Document Has Been Signed on 12/07/2023 01:08 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: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: 3DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Myat TusawTIME COMPLETED:
01:22 PM
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On 12/7/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Administrator, Myat Tusaw.

LPA reviewed resident records and personnel records. Medication records reviewed. Medications observed to have original labels and be administered as prescribed. Last fire drill was conducted on 11/15/2023. Fire extinguisher last serviced 11/24/2023. Smoke detector and carbon monoxide detector observed to be operational during today's visit.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. Resident bathrooms were properly equipped with grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 116.6 degrees F in the bathroom. Kitchen toured, appeared clean, LPA observed an adequate food supply. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

No deficiencies issued during this inspection.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Myat Tusaw, whose signature on these forms confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/21/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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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