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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209003
Report Date: 11/02/2023
Date Signed: 11/03/2023 01:13:25 PM

Document Has Been Signed on 11/03/2023 01:13 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:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Administrator, Ronald DuranTIME COMPLETED:
02:18 PM
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Licensing Program Analyst conducted an Annual Inspection visit. LPA Williams met with Administrator, Ronald Duran and discussed the purpose of the visit.

LPA Williams toured the facility with Staff 1.

The kitchen was sanitary and in good repair. There were 2 days of perishable food and 7 days nonperishable food.

The dining and living room had seats to accommodate all clients. The facility thermostat reflected 71 degrees Fahrenheit (F).

LPA Williams observed four bedrooms. Each bedroom had a bed, with required linens, night stand, dresser, chairs, and working light. All bedrooms had space for clients to move around and the rooms were personalized.

Two bathrooms were sanitary and in good repair. There were non-slip mats and grab bars available for client use.

Smoke detectors and carbon monoxide detectors were present and operational. First aid kit was present and had all required items.

LPA observed medications and chemicals to be locked and inaccessible to clients.

*Continued on LIC 809C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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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: KOOTENAY COURT
FACILITY NUMBER: 157209003
VISIT DATE: 11/02/2023
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The backyard had a covered shaded area for client use. There is no pool on the premises.

LPA reviewed four client files and two employee files. All clients had documents that were requested for review. LPA requested an updated medical assessment for Resident 2 to clarify information. Employee files had documents that were requested.

No deficiency was cited during this visit.

LPA requested the following documents be provided to the Department: Liability Insurance, LIC 500 and LIC 308.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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