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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203519
Report Date: 04/07/2022
Date Signed: 04/08/2022 10:49:18 AM

Document Has Been Signed on 04/08/2022 10:49 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:INDEPENDENCE AT CENTENNIAL GROVEFACILITY NUMBER:
157203519
ADMINISTRATOR:ESPARZA, DANIELFACILITY TYPE:
735
ADDRESS:8218 MAPLE GROVE LNTELEPHONE:
(661) 587-9499
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 4CENSUS: 4DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Daniel EsparzaTIME COMPLETED:
10:25 AM
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On 04/07/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with caregiver Crystal Moore and house manager Rita Wormely. Administrator Daniel Esparza was called and arrived later during inspection. LPA conducted tour with house manager. There are two clients present during tour.

Upon entry facility staffs was observed with facial mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing etiquette postings in facility. Cough etiquette postings not observed in facility.

All clients’ room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. Cleaning supplies were stored and locked under kitchen sink and hall closet.

The exterior tour was conducted. Side gate was self-closing and self-latching. LPA checked clients’ locked medications and observed a 30-day PPE supplies. Staff records were reviewed for good health and infection control training. All clients’ records reviewed to have updated emergency contact information. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 11/08/21. Last fire drill: 03/01/22.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 04/13/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500. LPA received copy of Administrator Certificate, Lic 610D, Lic 9020 during facility inspection.Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Signature on file.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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