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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209066
Report Date: 08/26/2021
Date Signed: 08/26/2021 12:26:22 PM

Document Has Been Signed on 08/26/2021 12:26 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:PURPOSEFUL RESIDENTIAL CARE: WELLMAN PLACEFACILITY NUMBER:
157209066
ADMINISTRATOR:VICKERS, TYSON W.FACILITY TYPE:
735
ADDRESS:809 WELLMAN WAYTELEPHONE:
(661) 412-4541
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 5DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Administrator, Tyson VickersTIME COMPLETED:
12:14 PM
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Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator, Tyson Vickers, and discussed the purpose of the visit.

LPA Williams toured the facility.

LPA Williams observed a visitor/temperature log, masks, and disinfection station at the front entrance. Facility has one entry and 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 Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies and medication were observed behind a locked door. LPA Williams observed the following personal protective equipment in the garage; gloves, and masks.

LPA Williams observed staff training records regarding Covid-19 mitigation and infection control. LPA Williams observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

No deficiencies were observed at the facility.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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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