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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209189
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:20:39 AM

Document Has Been Signed on 01/27/2023 11:20 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: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: 6DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Licensee, Carol ApistarTIME COMPLETED:
11:34 AM
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On 01/27/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection - infection control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Licensee, Carol Apistar, who arrived a short time later.

LPA conducted a facility tour with Licensee. COVID-19 guidelines are in place. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors at facility entrance. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lids. Hand washing posters were observed by the bathroom sink. There are three single occupant bedrooms and two shared bedrooms. Beds in the shared rooms appeared to be a least 6 feet apart.

LPA checked residents' medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility staff was observed with facial coverings. Resident’s files had updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 02/10/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond

No deficiencies issued. An exit interview was conducted. A copy of this report was discussed and provided to Licensee, Carol Apistar, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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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