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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202782
Report Date: 03/28/2023
Date Signed: 03/29/2023 03:18:12 PM

Document Has Been Signed on 03/29/2023 03:18 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:CHESHIREFACILITY NUMBER:
157202782
ADMINISTRATOR:SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:2417 CHESHIRE DRIVETELEPHONE:
(661) 836-1886
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 3DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Administrator, Gonzalo CruzTIME COMPLETED:
02:22 PM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced annual inspection visit. LPA Williams met with Administrator, Gonzalo Cruz and discussed the purpose of the visit.

LPA Williams and the Administrator toured the facility.

LPA Williams observed two couches in the living room which were clean and in good repair.

The kitchen and dining room were in clean and good repair. The kitchen water temperature reflected 112 degrees Fahrenheit (F) via hand held thermometer. There was one week of perishable and two week of non perishable food.

Three of the four bedrooms were occupied. LPA Williams observed a working light, beds with required linen, night stand, dresser, and chair in the room. The rooms were clean, good repair, and had no odor.

Extra linens and hygiene items were observed in the hallway closet.

Two of two bathrooms in the facility were clean and in good repair. Water temperatures via handheld thermometer, reflected 108 degrees F.

Sharps, chemicals, and medications were all observed to be locked and inaccessible to clients.

Smoke detectors, carbon monoxide, and fire extinguishers were all present and operational.

*Continued on LIC 809C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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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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: CHESHIRE
FACILITY NUMBER: 157202782
VISIT DATE: 03/28/2023
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LPA Williams reviewed three of three client files. All files had required documentation.

No deficiencies were observed.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC809 (FAS) - (06/04)
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