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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209066
Report Date: 09/18/2023
Date Signed: 09/19/2023 07:55:32 AM

Document Has Been Signed on 09/19/2023 07:55 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:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Agnes Fanoy, House ManagerTIME COMPLETED:
03:45 PM
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On 9/18/23, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit and allowed entrance by direct support staff. Tyson Vickers, Administrator was not available during today's inspection. LPA met with Agnes Fanoy, House Manager to conduct today's inspection.

Facility tour conducted with House Manager. Five residents were present at start of inspection visit. Residents observed to be watching television in the living room, relaxing in their room, or leaving for outing in community. Facility observed to be clean and odor free, well lit, and have adequate seating throughout facility for all residents. Resident bedrooms toured and observed to have required furnishings available. Kitchen toured, facility has a 2-day supply of perishable and a 7-day supply of non-perishable food available. All knives are locked in pantry in kitchen. Resident bathrooms toured, and observed to be in good repair. Hot water measured at 113 degrees F during facility inspection.

Fire Extinguisher present with a service date of 5/10/23. Carbon monoxide and smoke detectors tested and observed operational during today's inspection. First Aid kit observed to have all regulation items. All cleaning chemicals are locked and secured in cabinet in the garage.

Outside of facility toured. Pool is locked, secured and inaccessible to residents. All exits open are free of obstruction. No hazards observed.

No deficiencies observed during facility inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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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