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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206719
Report Date: 11/16/2022
Date Signed: 11/21/2022 03:29:21 PM


Document Has Been Signed on 11/21/2022 03:29 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:PARK RCFE, THEFACILITY NUMBER:
157206719
ADMINISTRATOR:MALONE, CATHYFACILITY TYPE:
740
ADDRESS:311 GARNSEY AVENUETELEPHONE:
(661) 283-4160
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:9CENSUS: 5DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Administrator, Cathy MaloneTIME COMPLETED:
04:49 PM
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Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator, Cathy Malone, and discussed the purpose of the visit. LPA Williams toured the facility with Administrator.

LPA Williams observed a visitor/temperature, masks, and disinfection station at the front entrance. Facility has one entry and exit point.

LPA Williams observed a two day supply of perishable food and 7 day non-perishable food. Cleaning supplies and medications were observed behind a locked door. LPA Williams observed all facility staff wearing masks.

Staff have received training regarding Covid-19 infection control and mitigation. 5 of 5 residents emergency contact information was up to date.

LPA Williams requested the following documents be sent to the Department by 11/23/2022; personnel report (LIC 500) ,designation of facility responsibility (LIC 308), and Administrator certificate.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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