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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203376
Report Date: 05/06/2022
Date Signed: 05/09/2022 08:13:32 AM


Document Has Been Signed on 05/09/2022 08:13 AM - 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:ABLE CARE HOMES 1FACILITY NUMBER:
157203376
ADMINISTRATOR:ZAPATA, BARBARAFACILITY TYPE:
740
ADDRESS:10005 COBBLESTONE AVENUETELEPHONE:
(661) 858-0385
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 3DATE:
05/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Barabara Zapata, Licensee TIME COMPLETED:
03:15 PM
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On 05/06/2022, Licensing Program Analyst (LPA) L. Salazar and A. Walton arrived at the facility unannounced to conduct a case management on an incident report that was received on 04/22/22. LPAs were greeted by Licensee (L1), explained the purpose of the visit and were allowed entry into the facility. COVID precautionary measures were taken prior to entry.

L1 submitted an Incident report to CCL stating that Resident R1 claimed they were in a lot of pain and became hysterical. Facility called 911 and R1 was transported to hospital. R1 did not return to the facility and will remain with family. LPA reviewed resident's file and observed required LIC forms and documentation.

No deficiencies cited on today's visit. Exit interview conducted.


SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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