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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209196
Report Date: 03/14/2024
Date Signed: 03/14/2024 07:16:48 PM


Document Has Been Signed on 03/14/2024 07:16 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: 5DATE:
03/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Administrator Socorro TelmoTIME COMPLETED:
07:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Shawna Doucette and Lisa Salazar arrived at the facility unannounced to conduct a complaint investigation. During the course of the investigation LPA observed additional deficiencies. LPA met with Administrator Socorro Telmo.

LPA interviewed staff. LPA reviewed records for R1 and R2. Facility is fire cleared for one bedridden resident in Room 5. Upon review of records, it was found R1 and R2 are both bedridden. R1 is in Room 1 and R2 is in Room 2. Neither room 1 or 2 are fire cleared

Refer to 809d. Civil penalties issued for fire clearance.

A copy of this report with plan of correction and appeal rights were provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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Document Has Been Signed on 03/14/2024 07:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: TAR SPRINGS HOME CARE
FACILITY NUMBER: 157209196

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
87202(a)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the
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Plan of Correction POC Licensee agrees to submit LIC200, LIC 9054, facility sketch and 610D by POC due date 03/15/24.



Civil Penalties issued.
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licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: Licensee has 2 out of 5 residents bedridden and is only fire cleared for one resident in room 5. R1 is in room 1 and R2 is in room 2 which are not fire cleared rooms which poses and immediate health safety and or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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