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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208933
Report Date: 11/06/2023
Date Signed: 11/06/2023 01:03:00 PM

Document Has Been Signed on 11/06/2023 01:03 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:NEMIA HOMEFACILITY NUMBER:
157208933
ADMINISTRATOR:GO, CELESTEFACILITY TYPE:
734
ADDRESS:3256 JENKINS RDTELEPHONE:
(650) 238-4987
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 5CENSUS: 5DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Administrator, Celeste GoTIME COMPLETED:
01:15 PM
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On 11/062023, Licensing Program Analyst (LPA) Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self and stated the purpose of the visit and was allowed entry to the facility. Facility staff contacted Administrator, Celeste Go via telephone. Administrator arrived a short time later.

LPA conducted a tour of the facility with Administrator. During the inspection the facility appeared clean and odor free and at a comfortable temperature. Common areas were furnished and had adequate seating and lighting available. Resident bedrooms appeared clean and had required furnishings and adequate lighting. Residents bathrooms appeared clean, water temperature measured at 105.5 degrees F in the bathroom near bedrooms 1 and 2, and 106.1 degrees F in the bathroom near bedrooms 3, 4, and 5. Facility kitchen appeared to be clean and safe for food preparation. LPA observed 2-day supply of perishable foods and a 7-day supply of non-perishable food.

Exterior tour conducted, all exits open and free of obstructions on today’s visit. Fire extinguishers are current with a service date of 02/13/2023. Smoke detectors and carbon monoxide detector observed to operational. Last fire drill conducted on 11/01/2023. Cleaning supplies observed to be locked in a cabinet in the garage. LPA reviewed client and staff files. Medications observed to be locked and administered as prescribed.

No deficiencies issued. 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.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/20/2023: 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 (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020), Surety Bond.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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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