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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209196
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:17:41 PM


Document Has Been Signed on 04/25/2022 03:17 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:TAR SPRINGS HOME CAREFACILITY NUMBER:
157209196
ADMINISTRATOR:TELMO, SOCORRO ANNFACILITY TYPE:
740
ADDRESS:2804 TAR SPRINGS AVENUETELEPHONE:
(661) 831-3430
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:6CENSUS: DATE:
04/25/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Administrator Socorro Ann Telmo TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) K.Kaur conducted a Pre-licensing Inspection on this date. LPA met with Administrator Socorro Ann Telmo. A tour of the facility was conducted together.

The facility has 5 bedrooms designated for residents. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas were properly furnished and well-lit throughout. Fire extinguisher was observed with a service date of: 12/7/2021. Smoke detectors and carbon monoxide detector were tested and observed to be operational. The First Aid Kit was observed to have the required supplies. There is a locked cabinet in the kitchen for medications. Cleaning supplies and chemicals are locked in the garage.

The tour started in the Kitchen and proceeded to living area and resident's bedrooms. Knives will be locked in the kitchen. Night lights are in place in the hallways. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lightning. Mattresses and box springs were in good condition. A sufficient supply of linens was observed. Bathrooms were properly equipped, and trash cans had a fitting lid. Grab bars and non-skid mats are installed and in place. Hot water was tested at 109-degrees F in the bathroom. Patio has a covered sitting area and a self-latching gate was observed in the backyard. Required postings were observed. Component III was also conducted and completed. Exit interview was conducted.

Pre-licensing requirements were met.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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