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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203519
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:59:50 AM

Document Has Been Signed on 08/31/2023 11:59 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:
08/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Eric Coronado TIME COMPLETED:
12:20 PM
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On 8/31/23, Licensing Program Analyst (LPA) M. Medina conducted a case management to follow up on a self reported incident that occurred on 8/19/23 with S1 and R1.

On day of incident S1, was interviewed and then released to go home by Administrator, the following day S1 was notified to not show up for mid day shift from 11:00 AM - 7:00 PM. On 8/21/23, S1 was interviewed at MARS Administrative office, a few days later at conclusion of investigation S1 was terminated.

LPA gathered copies of R1's IPP and emergency contact information and S1's employee file was scanned and emailed to LPA.

Follow up visit to be conducted if needed.

No deficiencies issued at time of visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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