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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209178
Report Date: 12/10/2024
Date Signed: 12/10/2024 04:29:13 PM

Document Has Been Signed on 12/10/2024 04:29 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/
DIRECTOR:
VICKERS, ADONICAFACILITY TYPE:
735
ADDRESS:503 HASWELL STREETTELEPHONE:
(661) 829-7125
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 6DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:03 PM
MET WITH:Adonica Vickers
Idelli Ervin
TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 12/10/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection visit. LPA arrived, introduced self, and allowed entrance by House Manager, Idelli Ervin. Licensee/Administrator, Adonica Vickers contacted by telephone and arrived during inspection visit.

Facility tour conducted with House Manager. Facility is a 5 bedroom, 2 bathroom home with 4 private bedrooms and 1 shared bedroom. Facility observed to be clean, odor free, and a comfortable temperature. Residents observed to be engaged in holiday activities with staff during inspection. All common areas of facility observed to have adequate seating available for residents in care. Facility tour began in resident bedrooms, all bedrooms observed to have adequate lighting and required furnishings. Resident bathrooms toured, showers observed to have grab bars and shower chairs available. All bathrooms, observed to have hand soap and paper towels available. Water temperature measured at 112 degrees F. Kitchen toured, all knives observed to be locked and secured in pantry. Facility observed to have a 2-day supply of perishable and a 7-day supply perishable food available. All food in the refrigerator observed to be properly stored and labeled. Medication observed to be locked and secured in hallway closet. Medication reviewed and observed to have original labels and to be administered as prescribed.

Fire extinguisher present and observed to have a service date of 8/20/2024. Carbon monoxide and smoke detectors observed operational during inspection. Last emergency disaster drill and fire drill conducted 12/09/24 according to facility records.

Outside of facility toured. All exits open free of obstruction. Pool is surrounded by a locked 6 foot fence and inaccessible to residents.

Staff and resident files reviewed.

No deficiencies cited during inspection. Exit interview conducted and a copy of report provided to Licensee for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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