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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208782
Report Date: 03/24/2022
Date Signed: 03/25/2022 01:56:21 PM


Document Has Been Signed on 03/25/2022 01:56 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:KENNY ELDERLY CARE FACILITYFACILITY NUMBER:
157208782
ADMINISTRATOR:BARAJAS, JUDITHFACILITY TYPE:
740
ADDRESS:4804 KENNY STREETTELEPHONE:
(661) 900-4434
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY:6CENSUS: DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Judith Barajas TIME COMPLETED:
01:50 PM
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On 03/24/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Caregiver Maria Becerra. Five residents were present during the inspection.

Visitor log-in/temperature check, masks, and disinfection station were 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. Facility tour conducted with caregiver.

All pathways, entrances and exits were clear from obstructions. No fire clearance issues. Resident rooms were toured and were observed with required furniture. Bathrooms were properly equipped with non-skid mats and securely fastened grab bars. Linens and hygiene items were observed. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher was observed with a service date of: 3/4/22. Cleaning supplies and chemicals were observed in the locked garage with the laundry. LPA reviewed a sample of the medications and MARs that are kept in the locked closet in the hallway. Staff files were reviewed for good health and are current with CPR. No deficiencies were observed.

Please submit the following forms to CCL by: 3/28/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC 610E),Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.


An exit interview was conducted with Administrator. As a COVID-19 precautionary measure, a copy of this report will be provided via email. Report signed on-site by Facility Administrator.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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