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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208785
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:29:05 AM


Document Has Been Signed on 11/04/2022 11:29 AM - 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:TEDENEK ELDER HOME 2FACILITY NUMBER:
157208785
ADMINISTRATOR:TUSAW, MYATFACILITY TYPE:
740
ADDRESS:13001 BIRKENFELD AVETELEPHONE:
(661) 496-6432
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 0DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Adminstrator, Myat TusawTIME COMPLETED:
11:42 AM
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On 11/04/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Administrator, Myat Tusaw.

There are currently no residents residing in the facility and the facility is not staffed.

Facility tour conducted with Administrator. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA checked food supply, observed an adequate supply of food. Facility has an adequate supply of cleaning supplies. Facility has a sufficient amount of PPE supplies. Bathrooms are stocked with liquid soap and paper towels. Bedrooms toured. LPA observed required furnishings.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/14/2022: 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 (LIC610-D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Myat Tusaw, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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