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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209066
Report Date: 08/02/2022
Date Signed: 08/02/2022 10:52:08 AM

Document Has Been Signed on 08/02/2022 10:52 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: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:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Adonica VickersTIME COMPLETED:
11:00 AM
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On 8/2/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Infection Control Inspection. LPA introduced self and allowed entrance by Direct Care. All COVID protocols are in place, sign in roster, temperature check, hand sanitizer available throughout facility. Tyson Vickers, Administrator Certificate #6051086735, expires 10/23/2023.

Facility tour conducted with Licensee, Adonica Vickers. LPA observed 5 residents present and 4 staff working. All common areas have sufficient lighting and seating for residents in care. Kitchen toured, menu observed to be posted on information board. Facility has a 2-day supply of perishable and 7-day supply of non-perishable available. All sharps are locked and secured in kitchen pantry. Three resident bedrooms are all private, the shared room has a minimum of 6 feet between beds. Resident bathrooms toured, LPA observed paper towels, hand soap, and hand washing signs available. Chemicals are locked and secured in kitchen cabinet as well as locked cabinet in the garage. Medication is locked and secured in hallway closet. All resident's have a 30-day supply of medication. Fire extinguisher present with a date of service of 5/06/22.

Outside of facility toured. Pool area is surrounded by locked perimeter fence and not accessible to residents.

No deficiencies cited during today's inspection.

Exit interview conducted. A copy of this report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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