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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204184
Report Date: 12/28/2021
Date Signed: 12/29/2021 12:10:25 PM

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:LERWICK HOME CAREFACILITY NUMBER:
157204184
ADMINISTRATOR:ROSALES, BONAFEFACILITY TYPE:
740
ADDRESS:10213 LERWICK AVENUETELEPHONE:
(661) 665-2874
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 6DATE:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Bonafe Rosales, Licensee TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) L. Salazar conducted an unannounced Annual Visit. LPA Salazar met with Licensee, Bonafe Rosales and discussed the purpose of the visit.

LPA Salazar toured the facility with the Licensee. LPA observed 5 bedrooms and 3 bathrooms in the facility. Facility staff was observed with masks on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Social distancing is maintained in the common and dining areas. LPA observed resident's medications in a locked cart located in the kitchen.

LPA observed hand washing posting and other various Covid-19 related signs prior to entering the facility.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. LPA observed the following supply of personal protective equipment; gloves, hand sanitizer and masks.

LPA observed plan for Covid-19 mitigation and infection control. Resident files have updated emergency contact information.

No deficiencies were cited. Exit interview was conducted with the Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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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