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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209178
Report Date: 12/01/2021
Date Signed: 12/01/2021 11:42:24 AM

Document Has Been Signed on 12/01/2021 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:PURPOSEFUL RESIDENTIAL CARE: HASWELL PLACEFACILITY NUMBER:
157209178
ADMINISTRATOR:VICKERS, ADONICAFACILITY TYPE:
735
ADDRESS:503 HASWELL STREETTELEPHONE:
(661) 829-7125
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 0DATE:
12/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Licensee, Adonica and Tyson VickersTIME COMPLETED:
11:32 AM
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Licensing Program Analyst (LPA) Darius Williams conducted a Pre licensing visit. LPA Williams met with Licensee, Adonica and Tyson Vickers and discussed the purpose of the visit.

LPA Williams toured the facility with the Licensee, which began at the front entrance.

LPA Williams observed no obstructions or bodies of water in the front yard. The designated side gate exit was self latching and free of obstruction.

The living room was clean, had a large sectional couch, and space to accommodate clients. A facility phone was present and functional.

Utensils, plates, cups, bowls, and cook ware were present in the kitchen. The stove, microwave, and refrigerator were all functional. The refrigerator temperature reflected 35 degrees Fahrenheit., the freezer 0 degrees F., and the sink water reflected 106.1 degrees F., via handheld thermometer. Next to the kitchen was a dining table with seating for 6 individuals.

Roomss 1, 2, 3, 4, and 5 all had beds, with mattresses, mattress cover, linens, blanket, pillow, and pillow case. All bed rooms had dressers, lights, chair, and were clean, and in good repair.

The bathrooms were equipped with non-slip mats, clean, and in good repair.

LPA Williams observed a supply of personal hygiene items, linens, washcloths, and towels.

*Continued on LIC 9099-C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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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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: PURPOSEFUL RESIDENTIAL CARE: HASWELL PLACE
FACILITY NUMBER: 157209178
VISIT DATE: 12/01/2021
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The backyard had a covered patio area with seating and the pool was surrounded by a fence that was locked.

The garage was clean, in good repair, and utilized for extra storage of supplies.

LPA Williams observed knives, chemicals, and designated medication storage area, behind locked closet doors, in the kitchen and hallway.

Fire extinguisher was present and charged. Both the smoke detectors and carbon monoxide detector were present and functional.

Pre-licensing is complete and this facility has no deficiencies.

LPA Williams completed Component III with the Licensee.

A License has not been issued to the Licensee at this time. This report has been provided to Central Applications Bureau for further action.

An exit interview was conducted and a copy of this report was provided to the Licensee.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC809 (FAS) - (06/04)
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