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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203519
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:29:16 PM

Document Has Been Signed on 10/15/2024 03:29 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:INDEPENDENCE AT CENTENNIAL GROVEFACILITY NUMBER:
157203519
ADMINISTRATOR/
DIRECTOR:		CORONADO ERICFACILITY TYPE:
735
ADDRESS:8218 MAPLE GROVE LNTELEPHONE:
(661) 587-9499
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 4CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:43 PM
MET WITH:Rita Wormely TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 10/15/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit to follow up on an incident that occurred on 10/08/24 and was self reported by facility to Fresno Regional Office on 10/09/24.

LPA arrived, introduced self, and allowed entrance by staff. Administrator, Eric Coronado contacted by telephone and was not available to come to meet with LPA. LPA spoke with Administrator over the telephone and advised of purpose of visit.

LPA received copy of R1's most current IPP during facility visit. R1 was not present during time of visit.

No deficiencies cited during inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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