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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208805
Report Date: 08/18/2022
Date Signed: 08/18/2022 11:43:34 AM


Document Has Been Signed on 08/18/2022 11:43 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:PROVEDENTIS DEI CARE HOME IFACILITY NUMBER:
157208805
ADMINISTRATOR:MARASIGAN, VANNIFACILITY TYPE:
740
ADDRESS:207 RIESLING VINES STREETTELEPHONE:
(661) 829-5862
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 1DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Administrator Rodrigo ArrietaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Staff Emma Culion and discussed the purpose of the visit. Administrator Rodrigo Arrieta responded to the facility to conduct the visit. LPA and Administrator toured the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed locked in closet. LPA observed the following personal protective equipment in a closet; hand sanitizer, face shield, gloves, and masks. Resident’s files have updated emergency contact information.


No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided via email.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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