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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202782
Report Date: 01/29/2025
Date Signed: 01/29/2025 02:41:06 PM

Document Has Been Signed on 01/29/2025 02:41 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CHESHIREFACILITY NUMBER:
157202782
ADMINISTRATOR/
DIRECTOR:		SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:2417 CHESHIRE DRIVETELEPHONE:
(661) 836-1886
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator: Gonzalo CruzTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 1/29/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Adrianna Garza. LPA was granted entry. Administrator (A1) Gonzalo Cruz arrived shortly after LPA’s arrival. 2 residents were present during visit. The other 2 attended day program. 1 of the 2 that attended day program arrived to facility during visit.

LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. LPA advised be repaired or replaced. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 31 degrees F. Thermometer was installed to check temperature. LPA advised to have a thermometer for both the freezer and refrigerator in at all times. Fire extinguisher was observed with a purchase date of: 9/2/24. No record of fire drill documented in facility. Washer and dryer observed operational during visit. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature ranging from 111.3 to 113.1 degrees F. in bathrooms 1 and 2. Non-skid mats observed in both bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with outdoor seatings available for residents. 1 out of 4 chairs missing and is in need of purchase. Samples of medications were checked and observed kept locked in the cabinet. Residents’ MARS was reviewed. First aide kit observed with all of the required items.

All residents files and samples of staff files reviewed to have all the required documents.


SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CHESHIRE
FACILITY NUMBER: 157202782
VISIT DATE: 01/29/2025
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1 deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Technical Violations assigned to Licensee. Licensee agrees to conduct fire drill and submit fire drill log to CCLD. A copy of LIC 9102 issued to Licensee. Licensee to submit photos of thermometers, Facility Sketch framed and posted, Ombudsman Poster, blinds, and chair and receipt of all purchases to CCLD.

Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 2/12/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), (LIC610D- Adult), Personnel Report (LIC500), Register of Facility Clients/Residents for Personal Rights (LIC9020 – Adult), and Surety Bond. Technical Support Services were offered and referred to facility.

A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2025 02:41 PM - It Cannot Be Edited


Created By: Jacques Leffall On 01/29/2025 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CHESHIRE
FACILITY NUMBER: 157202782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 fire drill log, not present in facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Licensee agrees to conduct a quarterly fire drill and document in Fire Drill log. Licensee agrees to submit copy of Fire Drill log to Fresno CCLD by POC due date.
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:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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