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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204005
Report Date: 10/16/2024
Date Signed: 10/16/2024 03:27:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/16/2024 03:27 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:SIERRA SPRINGS RESIDENTIAL CAREFACILITY NUMBER:
157204005
ADMINISTRATOR/
DIRECTOR:		NANKIL, PATRICKFACILITY TYPE:
735
ADDRESS:305 DANI ROSE LANETELEPHONE:
(661) 399-4787
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 4CENSUS: 4DATE:
10/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Patrick NankilTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/16/24, Licensing Program Analysts (LPAs) M. Medina and L. Salazar arrived to the facility unannounced to conduct the required annual inspection. LPAs arrived, stated the purpose of the visit and were allowed entry into the facility by direct care staff. Administrator, Patrick Nankil, contacted by telephone and arrived a short time later to conduct inspection.

LPA Medina reviewed a sample of staff and resident files and observed the files to have the required documentation and staff training's. LPA reviewed Emergency Disaster plan and observed the binder to have the required updated information.

LPA Salazar will document the physical plant tour and inspection tool results on a separate report.

Facility to submit the following documents to Fresno Regional Office no later 11/01/24: LIC 309 Administrative Organization, LIC 500 (Personnel Report), LIC 9020 (Register of Facility Clients/Residers), Copy of Surety Bond, Copy of Administrator Certificate and CPR/First Aid card.

No deficiencies cited.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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