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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202782
Report Date: 03/26/2024
Date Signed: 03/26/2024 03:31:14 PM

Document Has Been Signed on 03/26/2024 03:31 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:
03/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Care staff, Susan Sanchez
Administrator, Gonzalo Cruz		TIME COMPLETED:
03:28 PM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Annual Visit. LPA Williams met with staff Sanchez, and discussed the purpose of the visit. Administrator, Gonzalo Cruz arrived later.

LPA Williams and Susan toured the facility.

LPA Williams observed two couches in the living room which were clean and in good repair. Facility thermostat reflected 70 degrees Fahrenheit(F)

The kitchen and dining room were in clean and good repair. The kitchen water temperature reflected 110 degrees 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: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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: 03/26/2024
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First Aid kit was present and had all required items.

There is no pool on the premises.

LPA reviewed 3 clients files and 3 employee files. All client files had documents that were requested by the LPA. LPA directed Administrator to get clarification on a diagnosis regarding Resident 2. All employee files had documents requested by the LPA.

No deficiencies were cited during this visit.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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