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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209066
Report Date: 10/25/2022
Date Signed: 10/25/2022 01:01:03 PM

Document Has Been Signed on 10/25/2022 01:01 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:
10/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Agnes FanoyTIME COMPLETED:
01:06 PM
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On 10/25/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit. LPA introduced self and allowed entrance by Direct Care Staff. LPA Medina met with Agnes Fanoy, House Manager and also spoke with Adonica Vickers, Licensee/Administrator via telephone and stated reason for visit.

LPA Medina conducted Case Management visit to verify if Staff 1 (S1) is currently working in the facility. LPA verified with Licensee that S1 has not been worked in facility since April 2021 and was terminated in October 2021. Licensee was advised an exclusion has been ordered and issued by the Department. Licensee will disassociate S1 from facility personnel report through Guardian.

No deficiencies sited during this Case Management visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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