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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157207096
Report Date: 09/22/2021
Date Signed: 09/22/2021 03:38:38 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:WINDCREEK SENIOR CAREFACILITY NUMBER:
157207096
ADMINISTRATOR:TUNGPALAN, FE V.FACILITY TYPE:
740
ADDRESS:9300 WINDCREEK CT.TELEPHONE:
(661) 387-6582
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 6DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Administrator, Fe TungpalanTIME COMPLETED:
03:38 PM
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Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator, Fe Tungpalan and discussed the purpose of the visit.

LPA Williams toured the facility with the Administrator.

LPA Williams observed a visitor/temperature log, masks, gloves, and disinfection station 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; gown, face shield, gloves, masks, head covers, and shoe covers. LPA Williams observed all facility staff wearing masks.

Staff have received training regarding Covid-19 infection control and mitigation. 6 of 6 resident’s files had updated emergency contact information.

LPA Williams requested the following documents be sent to the Department by 10/6/2021; personnel report (LIC 500) and designation of facility responsibility (LIC 308).

No deficiencies were observed.

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: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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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