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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203451
Report Date: 01/25/2023
Date Signed: 01/25/2023 02:51:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/25/2023 02:51 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:MEADOW RISE FACILITYFACILITY NUMBER:
157203451
ADMINISTRATOR:BERNALES, AMABELLEFACILITY TYPE:
735
ADDRESS:624 MEADOW RISE COURTTELEPHONE:
(661) 399-2655
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 5CENSUS: 4DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amabelle Bernales, AdministratorTIME COMPLETED:
02:54 PM
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On 01/25/23, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct an Annual Inspection - Infection Control. LPA was greeted by staff S1, stated the purpose of the visit and was allowed entry into the facility. LPA called Administrator via telephone, who arrived to the facility a few minutes later. Administrator certificate number 6018122735 Expiration date 06/07/24. Facility has one central entrance and exit.

Facility tour conducted. LPA observed a 5 bedroom / 2 bathroom home. One of the rooms is designated for live in staff. LPA observed 1 out of 4 residents at home during the visit. 2 of the 4 residents are currently at day program and 1 out of the 4 residents is working in the community.

LPA toured the facility kitchen and did not observe the required 7-day supply of non-perishables, however, a 2-day supply of perishables was observed. LPA observed cleaning supplies to be inaccessible in a locked cabinet in the garage. LPA observed an adequate supply of PPE and cleaning supplies. Medications checked. Medication observed in a locked cabinet in the kitchen.

LPA observed covered trash cans in bathroom and hand washing signs. Bathrooms were stocked with liquid soap and paper towels. Fire extinguisher was last serviced on 05/11/2022.

Resident bedrooms were checked. LPA observed the bedrooms to have the required furnishings and lighting. Rooms were free from odor, clutter and obstruction.

(Continued to 809C)
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: MEADOW RISE FACILITY
FACILITY NUMBER: 157203451
VISIT DATE: 01/25/2023
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(continued from 809)

LPA is requesting the following documents be submitted to the Fresno CCL office by 01/31/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

Exit interview conducted. No deficiencies cited. A copy of this report was discussed and provided to Administrator, Amabelle Bernales, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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