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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209146
Report Date: 03/06/2024
Date Signed: 03/06/2024 11:42:32 AM


Document Has Been Signed on 03/06/2024 11:42 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:QUALITY CARE ASSISTED LIVINGFACILITY NUMBER:
157209146
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2607 MT. VERNON AVENUETELEPHONE:
(661) 871-8133
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:54CENSUS: 35DATE:
03/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Ria LoriaTIME COMPLETED:
11:45 AM
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LPA Shawna Doucette arrived at the facility unannounced to conduct a case management regarding a death that occurred on with R1. LPA was granted entry into the facility by Administrator Ria Loria. LPA met with Administrator Ria Loria.

LPA interviewed Staff. LPA obtained copies of R1's records. LPA requested a copy of the death report which will be provided once received.

LPA will review records and return if deficiencies are found once records are reviewed.

An exit interview was conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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