157203451-3-3-2024-24-AS-LSAR-D3296A-20240303220510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157203451
Report Date: 01/30/2024
Date Signed: 03/03/2024 10:05:37 PM

Document Has Been Signed on 03/03/2024 10:05 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 FACILITY		FACILITY NUMBER:	157203451
ADMINISTRATOR:	BERNALES, AMABELLE		FACILITY TYPE:	735
ADDRESS:	624 MEADOW RISE COURT		TELEPHONE:	(661) 399-2655
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93308
CAPACITY: 5		CENSUS: 3	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Amabelle Bernales, Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE

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On 01/30/24, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Staff, stated the purpose of the visit and was allowed entry into the facility. Administrator arrived shortly after. LPA a toured he facility inside and out. on record is Amabelle Bernales, Certificate# 6018122735, Exp. 06/07/24.

LPA observed 3 residents in care at the time of visit. Facility is a 4 bedroom 2 bathroom home. Residents bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Facility temperature was 71 degrees F.

Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 120 degrees F. Trash can with lid and hand washing postings were observed.

Medications were observed to be locked in a cabinet located in the kitchen. Cleaning supplies were observed to be locked in the laundry room. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. There are no residents with Restricted Health conditions in the facility.

Carbon monoxide and smoke detectors were tested and observed to be operational. Night lights were observed. Fire Extinguisher was observed with a service date of 05/26/23. First aid kit was observed and contained all required items.

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: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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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Document Has Been Signed on 03/03/2024 10:05 PM - It Cannot Be Edited

Created By: Lisa Salazar On 01/30/2024 at 04:36 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: MEADOW RISE FACILITY	FACILITY NUMBER: 157203451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85087.2(b)

Outdoor Activity Space

(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not have a furnished outdoor area for resident use, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2024
	Plan of Correction
1 2 3 4	Administrator will purchase outdorr furnishing for residents' comfort outdoors.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Melinda Hoffmann

LICENSING EVALUATOR NAME:

Lisa Salazar

LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MEADOW RISE FACILITY	FACILITY NUMBER: 157203451
	VISIT DATE: 01/30/2024

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(continued from 809)

LPA is requesting the following documents be submitted to the Fresno CCL office by 02/16/2024: 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: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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