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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209085
Report Date: 09/03/2021
Date Signed: 09/07/2021 08:57:39 AM

Document Has Been Signed on 09/07/2021 08:57 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:MARIGOLD PALS HOUSEFACILITY NUMBER:
157209085
ADMINISTRATOR:HOUCK, HELEN S.FACILITY TYPE:
735
ADDRESS:212 HAGGIN STREETTELEPHONE:
(661) 742-1088
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 4DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Helen Houck, Licensee/AdministratorTIME COMPLETED:
12:30 PM
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On 9/3/21 at 10:30 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee Helen Houck arrived a short time later.

Facility was observed clean and without any obstructions or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. All residents have private bedrooms. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is valid.

No deficiencies cited during inspection.



The following updated forms are to be sent to CCL within 2 weeks:
LIC500, LIC400, LIC610D, LIC308, and surety bond.

Exit interview conducted. A copy of this report was emailed to HELENHOUCK@SBCGLOBAL.NET with read receipt to confirm receipt of this report.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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