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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203519
Report Date: 02/15/2024
Date Signed: 02/16/2024 08:29:09 AM

Document Has Been Signed on 02/16/2024 08:29 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:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Daniel Esparza
Eric Coronado		TIME COMPLETED:
03:02 PM
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On 2/15/2024, Licensing Program Analyst (LPA) M. Medina conducted an announced Annual Required Inspection. LPA Medina met with Administrators, Eric Coronado and Daniel Esparza

Currently, four residents in care. No residents were present during today's visit, two residents were attending day program and two residents were in the community with staff.

Facility tour conducted. Facility observed to be clean and odor free. Adequate seating and lighting observed in both the living room and dining room. Resident bedrooms have all required accommodations. Resident bathroom toured, LPA measured water temperature 114 degrees F. Kitchen toured, LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food available. Medications were observed to be locked and secured in medication cart. All medication observed to have original labels and appear to be administered as prescribed.

Smoke and carbon monoxide detector observed operational and mounted in the hallway. Fire extinguishers present and have a service date of 11/07/2023. Last fire drill conducted on 2/022024 according to facility records. Cleaning supplies observed to be locked and secured in hallway closet and additional supplies are secured under kitchen sink.

Outside area toured. All exits open free of obstruction, no hazards observed.

Staff and resident files reviewed. Administrator to submit the following forms to Fresno Regional Office no later than 2/29/24: LIC 308, LIC 500, LIC 9020, and copy of surety bond.

No deficiencies observed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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