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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204166
Report Date: 12/09/2021
Date Signed: 12/13/2021 03:50:15 PM

Document Has Been Signed on 12/13/2021 03:50 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:SCOTT RESIDENTIAL, LLCFACILITY NUMBER:
157204166
ADMINISTRATOR:SCOTT, CYNTHIAFACILITY TYPE:
735
ADDRESS:1013 N. SIERRA VIEW STREETTELEPHONE:
(213) 590-9304
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY: 4CENSUS: 1DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Cynthia ScottTIME COMPLETED:
12:45 PM
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Licensing Program Analyst LPAs K.Kaur and S. Doucette conducted an Annual Inspection on this date.
LPA(s) were met by Administrator Cynthia Scott who did temperature screening and conducted a facility tour.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one
entrance/exit point. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPAs observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning
supplies were observed in the kitchen locked cabinet under the sink. LPAs observed the following personal
protective equipment in a storage cabinet; gloves, masks, N95 masks. LPA observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

No deficiencies were observed.

Please submit the following forms/information to Fresno CCLD. Requested forms/ information: Current Copy
of Administrator’s Certificate, LIC308, LIC309, LIC400 (if applicable), LIC 500, LIC402 (If applicable), and
Plan LIC610D Emergency and Disaster. Exit interview was conducted and a copy of this report was provided
via email.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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