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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204005
Report Date: 09/28/2022
Date Signed: 10/04/2022 10:02:25 AM

Document Has Been Signed on 10/04/2022 10:02 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:SIERRA SPRINGS RESIDENTIAL CAREFACILITY NUMBER:
157204005
ADMINISTRATOR:NANKIL, PATRICKFACILITY TYPE:
735
ADDRESS:305 DANI ROSE LANETELEPHONE:
(661) 399-4787
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 4CENSUS: 4DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Caregiver, Liza Nacario and Administrator, Patrick NankilTIME COMPLETED:
11:34 AM
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On 09/28/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Patrick Nankil who gave LPA verbal permission to begin the inspection with Caregiver Liza Nacario. Administrator, Patrick Nankil arrived a short time later.

Facility tour conducted. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. Food supply checked. LPA observed an adequate food supply. LPA observed a 30 day supply of PPE and cleaning supplies.

There are 4 private bedrooms. Liquid soap and paper towels are available in the bathrooms. Hand-washing signs observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply. Resident and staff temperature checks are documented daily. Residents files were reviewed for updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/12/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020 and Surety Bond.

No deficiencies issued during this inspection. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Patrick Nankil, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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