157208931-5-2-2023-24-AS-LSAR-CRETYQ-20230501150908

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157208931
Report Date: 05/01/2023
Date Signed: 05/02/2023 02:18:19 PM

Document Has Been Signed on 05/02/2023 02:18 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:	AIMES COFFEE HOUSE		FACILITY NUMBER:	157208931
ADMINISTRATOR:	WRIGHT, MIRANDA		FACILITY TYPE:	738
ADDRESS:	6742 COFFEE RD		TELEPHONE:	(661) 589-9992
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93308
CAPACITY: 4		CENSUS: 2	DATE:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:07 PM
MET WITH:	Miranda "Mandy" Wright, Administrator		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/01/23, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. Administrator on record is Miranda Wright # 6026388735 Expiration 05/18/23. Administrator certificate is observed posted on the wall. LPA conducted a tour of the facility, inside and out. Facility temperature was 71 degrees F. There were no residents in care at the time of visit, residents were attending day program. Facility is a 4 bedroom 3 bathroom home. Private resident bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 113 degrees F. Trash can with lid and hand washing postings were observed. Internet devices and a working phone line were observed to be available for residents in care. A supply of extra linen's and towels were observed in the Hallway. Carbon monoxide and smoke detectors were tested and observed to be operational. Carbon Monoxide detectors are located in secondary living room, common hallway and resident bedroom hallways. A State Fire Marshall approved automatic fire sprinkler system was observed to be operational. Fire Extinguisher was observed with a service date of 01/17/23. First aid kit was observed and contained all required items. (Continued on 809-C)

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AIMES COFFEE HOUSE	FACILITY NUMBER: 157208931
	VISIT DATE: 05/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued from 809)

Medications were observed to be locked in closet located in hallway. Cleaning supplies were observed to be in a locked cabinet in the garage. The exterior tour of back yard was conducted and found to be free from debris. A covered outdoor seating area was observed for residents in care. Side gate was self-closing and self-latching.

Resident files were reviewed and observed to have update emergency contact information, Admission agreement, and current medical assessment, Individual Performance Plans, Individual Behavioral Support Plans, and an Individual emergency intervention plan. Needs and Service plans.

LPA reviewed Administrators personnel file and observed required health screening. Quarterly Earthquake & Fire Drill logs were observed for staff. Mandated Reporting requirements were provided and discussed with Administrator.

The following documents were obtained at the time if visit. LIC 500, LIC 9020, LIC 610D, Disaster Plan (facility’s emergency plan procedures). LPA requested the following be submitted to Fresno CCL by: 05/05/23: LIC 308, LIC 400, LIC 402,

An exit interview was conducted and a copy of this report was discussed and provided to licensee. No deficiencies cited on today's visit.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2