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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209003
Report Date: 10/18/2021
Date Signed: 10/18/2021 01:26:22 PM

Document Has Been Signed on 10/18/2021 01:26 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:KOOTENAY COURTFACILITY NUMBER:
157209003
ADMINISTRATOR:DURAN, RONALDFACILITY TYPE:
735
ADDRESS:2808 KOOTENAY COURTTELEPHONE:
(661) 412-8548
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
10/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator Ronald DuranTIME COMPLETED:
01:30 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Staff Shellie Ryan and discussed the purpose of the visit. LPA and Staff Shellie Ryan began the tour at the front entrance/office of the facility. Administrator Ronald Duran responded to the facility to assist with the inspection.

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 behind a locked in a kitchen cabinet and a hallway closet. LPA observed the following personal protective equipment in a locked hallway door; gowns, face shield, gloves, and masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing 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 to Administrator Ronald Duran.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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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