<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203519
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:11:03 AM

Document Has Been Signed on 03/22/2023 11:11 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:
03/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Rita WormelyTIME COMPLETED:
11:28 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/22/23, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self and stated purpose of visit, LPA allowed entrance by House Manager, Rita Wormely. Administrator, Daniel Esparaza by telephone and was not available to conduct facility inspection. Facility tour conducted with Support Staff, Pablo Perez. Daniel Esparaza, Administrator Certificate #6027466735, expires 10/27/2023.

Two residents present at start of today's inspection. Residents observed to be preparing for day program.

LPA conducted a complete tour of the facility with Licensee. Facility was observed at a comfortable temperature, clean, in good repair. The tour started in the residents' rooms. Residents bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Kitchen toured, LPA observed to have adequate supply for residents in care. Bathrooms were properly equipped and fixtures operational. Common areas were properly furnished and well-lit throughout. All medications observed to be locked and stored in cabinet. Medications observed to have original labels and be administered as prescribed.

Fire extinguisher was observed with a service date of 11/21/22. Carbon monoxide and smoke detectors were tested and observed to be operational. Cleaning supplies and chemicals were observed in the locked in closet.

Administrator to submit copy of Administrator certificate, CPR/First Aid car, LIC 500, LIC 610 and LIC 9020 to Fresno CCL office no later than 3/31/23.

No deficiency was observed. Exit Interview conducted.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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 1