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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204078
Report Date: 01/11/2023
Date Signed: 01/13/2023 10:52:06 AM

Document Has Been Signed on 01/13/2023 10:52 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:CELINE'S VILLAFACILITY NUMBER:
157204078
ADMINISTRATOR:SILVA, WENDYFACILITY TYPE:
735
ADDRESS:3621 KAPRAL WAYTELEPHONE:
(661) 564-8889
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
01/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Administrator, Wendy SilvaTIME COMPLETED:
02:24 PM
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Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator, Wendy Silva and discussed the purpose of the visit.

LPA Williams toured the facility with Administrator.

LPA Williams observed a visitor/temperature log at the front entrance. Facility has one entry and exit point. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies and medications were observed behind a locked door. LPA Williams observed the following personal protective equipment in storage; gowns, face shield, gloves, and masks. LPA Williams observed all facility staff wearing masks.

Staff have received training regarding Covid-19 infection control and mitigation. 4 of 4 client's files had updated emergency contact information.

LPA Williams requested the following updated documents be sent to the Department by 1/18/2023 ; personnel report (LIC 500) ,designation of facility responsibility (LIC 308),and administrator certificate.

No deficiencies were observed or cited at this time.

Exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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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