<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208933
Report Date: 11/21/2022
Date Signed: 11/21/2022 10:05:33 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/21/2022 10:05 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:NEMIA HOMEFACILITY NUMBER:
157208933
ADMINISTRATOR:GO, CELESTEFACILITY TYPE:
734
ADDRESS:3256 JENKINS RDTELEPHONE:
(650) 238-4987
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 5CENSUS: 4DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Administrator, Celeste GoTIME COMPLETED:
10:19 AM
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 11/21/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection - infection control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Celeste Go. Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one central entry and exit.

Facility tour conducted with Administrator. All pathways, entrances, and exits were clear from obstructions. No fire clearance issued observed during today's inspection. 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 throughout the facility.

Facility kitchen toured. LPA observed a two day supply of perishable food and seven day supply of non-perishable food. LPA observed an adequate supply of PPE and cleaning supplies. Medications checked. Resident bedrooms are single occupant. LPA reviewed resident records for updated emergency contact information.

No deficiencies issued during today's inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/05/2022: 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, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020

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

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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 1