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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203274
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:56:28 PM

Document Has Been Signed on 08/16/2022 12:56 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:E & E RESIDENTIAL #1FACILITY NUMBER:
157203274
ADMINISTRATOR:NELSON, BRIANFACILITY TYPE:
735
ADDRESS:2911 BERKSHIRETELEPHONE:
(661) 396-8579
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 4CENSUS: 4DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Sophia NelsonTIME COMPLETED:
01:00 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Infection Inspection on this date. LPA was met by Licensee Sophia Nelson and discussed the purpose of the visit. LPA and Licensee Sophia Nelson toured the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Covid-19 related signs were observed in the common areas.

Facility has a two day perishable and a seven day non perishable supply of food. Cleaning supplies were observed locked in a cabinet in the garage. LPA observed the following personal protective equipment in office; gowns, gloves, face shields, hand sanitizer and masks.


Resident’s files have updated emergency contact information.

LPA reviewed staff training for Covid.

An exit interview was conducted and copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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