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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209178
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:57:22 PM

Document Has Been Signed on 12/05/2023 01:57 PM - 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: 6DATE:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Adonica VickersTIME COMPLETED:
01:55 PM
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On 12/05/23, Licensing Program Analyst (LPA) M. Medina conducted an Annual/Required visit. LPA met with Licensee/Administrator, Adonica Vickers to conduct facility tour and record review. House Manager was authorized to sign report by Licensee.

Currently, there are six (6) clients in care. Facility tour conducted. Facility is a 5 bedroom home with 4 private bedrooms and 1 shared bedroom. Facility observed to be clean and odor free. Adequate seating and lighting observed in both the living room, and dining room. Client bedrooms have all required accommodations. Client bathroom toured, LPA measured water temperature 113 degrees F. Kitchen toured, LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food. Medications observed to be kept in a locked closet in hallway. Client medications were reviewed. All medication have their original labels and appear to be administered as ordered. All cleaning supplies are locked and secured in garage. Smoke detectors and carbon monoxide observed to be operational during today's inspection. Fire extinguisher present with a service date of 8/30/2023.

Outside of facility toured. Pool is surrounded by gate that is locked, secured, and inaccessible to residents. All exits open free of obstruction, no hazards observed.

LPA received email copy of administrator certificate during inspection visit. Administrator to submit updated LIC 308, LIC 500, and LIC 610 to Fresno RO no later than 12/15/23.

No deficiencies cited during today's visit. Exit interview conducted and a copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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