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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209085
Report Date: 09/14/2023
Date Signed: 09/18/2023 10:42:14 AM

Document Has Been Signed on 09/18/2023 10:42 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:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Helen HouckTIME COMPLETED:
11:33 AM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced annual inspection visit. LPA Williams met with Administrator, Helen Houck and discussed the purpose of the visit. All clients were out of the facility in appointments.

LPA Williams began the tour in the front door entry way. Required facility postings were observed in the entry way and through out the facility.

The living room was sanitary and had space to accommodate all clients. Dual fire alarm for smoke and carbon monoxide was present and operational. Facility thermostat reflected approximately 77 degrees Fahrenheit (F).

The dining room was sanitary and had a table with enough seats to accommodate all clients. The kitchen was next to the dining room and was also sanitary. There was two days of perishable food and seven days of nonperishable food.

LPA observed four clients bedrooms to be sanitary and free of obstruction. Each room had a bed, with required linens, chair, lamp, and dresser.

There are two bathrooms in the facility for client use. Both bathrooms were sanitary and free of obstruction. The showers had non-slip mats and the bathroom lights were operational.



*Continued on LIC 809C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MARIGOLD PALS HOUSE
FACILITY NUMBER: 157209085
VISIT DATE: 09/14/2023
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The backyard is free of obstruction and has a covered area for clients to remove themselves from direct sunlight. There is no pool on the premises.

LPA observed medications and cleaning chemicals to be locked and inaccessible to clients.

LPA reviewed two employee files and four clients files. All files had required documents that the LPA requested.

There was no deficiency observed during this visit.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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