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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203256
Report Date: 11/16/2022
Date Signed: 11/21/2022 03:30:16 PM

Document Has Been Signed on 11/21/2022 03:30 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:CARDIFFFACILITY NUMBER:
157203256
ADMINISTRATOR:SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:5804 CARDIFF AVENUETELEPHONE:
(667) 837-8177
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Administrator, Gonzalo CruzTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Darius Williams conducted an Annual Inspection on this date. LPA was met by staff and discussed the purpose of the visit. Administrator Gonzalo Cruz, arrived at a later time and conducted a tour with the LPA.

Temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked cabinet in the garage. LPA observed the following personal protective equipment in a storage cabinet in garage; gown, face shield, gloves, and masks.LPA observed all facility staff wearing masks. Staff retrieved training regarding Covid-19 and general infection control. Four of four resident’s files have updated emergency contact information.

LPA Williams requested the following documents be sent to the Department by 11/23/2022 ; personnel report (LIC 500), designation of facility responsibility (LIC 308), and Administrator certificate.

No deficiencies were cited.

An cxit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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