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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209189
Report Date: 01/31/2024
Date Signed: 01/31/2024 12:30:02 PM


Document Has Been Signed on 01/31/2024 12:30 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: 6DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Administrator Furaija LibaoTIME COMPLETED:
12:50 PM
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On 01/31/2024, Licensing Program Analyst (LPA) Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator via telephone. Administrator, Furaija Libao arrived a short time later. LPA met with Administrator.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured between 109.5 degrees F and 111.7 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable food and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher was last serviced on 01/15/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 09/03/2023. LPA reviewed staff and client records. Medications reviewed and observed to be administered as prescribed.

No deficiencies issued during today’s visit

Exit interview conducted with Administrator. A copy of this report was discussed and left with Administrator, Furaija Libao, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 02/14/2024: 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, and the facility Infection Control Plan

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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