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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209189
Report Date: 05/10/2022
Date Signed: 05/10/2022 01:52:06 PM

Document Has Been Signed on 05/10/2022 01:52 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:NANAS CAREFACILITY NUMBER:
157209189
ADMINISTRATOR:LIBAO, FURAIJA M.FACILITY TYPE:
740
ADDRESS:10301 REVERE BEACH DRIVETELEPHONE:
(901) 262-0260
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 2DATE:
05/10/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Furaija LibaoTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Shawna Doucette arrived to the facility unannounced to conduct the Post licensing visit. LPA Shawna Doucette met with Administrator Furaija Libao who granted LPA entry into the facility.

LPA toured facility. Hot water temperature in bathrooms measured at 116.1 degrees F. Cleaning supplies are stored in a locked cabinet under the sink. Medications are locked in a medication closet. Resident medication log/centrally stored log was reviewed. First aid kit contains all the required items. A fire extinguisher is present and has a service date of 10/26/2021. Fire alarm and carbon monoxide were tested and working.

LPA reviewed staff records and resident records.

No deficiencies were observed.

An exit interview was conducted with Administrator Furaija Libao and a copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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