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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209184
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:18:50 PM

Document Has Been Signed on 04/28/2023 03:18 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:AIMES PACINIFACILITY NUMBER:
157209184
ADMINISTRATOR:THOMAS, TATIANNAFACILITY TYPE:
737
ADDRESS:2700 PACINI STREETTELEPHONE:
(661) 589-9992
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 3CENSUS: 3DATE:
04/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Administrative Social Worker, Macy Varner and Operations Manager, Alexis RutledgeTIME COMPLETED:
03:32 PM
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On 04/28/2023, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Operations Manager, Alexis Rutledge and Administrative Social Worker, Macy Varner.

There are 3 out of 3 residents present during today's visit. Residents observed to be engaged in activities. LPA conducted a facility tour. Facility appeared clean, at a comfortable temperature and odor free. Food supply was checked. Facility has an adequate food supply. No fire clearance issues observed during today's inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by noon Monday 05/01/2023: resident roster, personnel roster, emergency/ID sheet for R1, admission agreement for R1, physician's report for R1, Needs / Services plan for R1, the job application and job description for S1, medical assessment for S1, criminal record clearance for S1, and any relevant documentation for S1.

No deficiencies issued during today's visit.

Exit interview conducted. A copy of this report was discussed and provided to operations manager, Alexis Rutledge, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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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