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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209207
Report Date: 04/26/2022
Date Signed: 04/27/2022 12:55:59 PM


Document Has Been Signed on 04/27/2022 12:55 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:YOUR LOVED ONES MATTER LLCFACILITY NUMBER:
157209207
ADMINISTRATOR:JIMENEZ, ISAIFACILITY TYPE:
740
ADDRESS:4804 KENNY STTELEPHONE:
(661) 491-3782
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY:6CENSUS: 6DATE:
04/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Isai JimenezTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) K.Kaur conducted a Pre-licensing Inspection on this date. LPA met with Administrator Isai Jimenez. A tour of the facility was conducted together.

This is an existing facility with six residents in placement. 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. There are four residents on hospice at this time. The dining room is equipped with a table and chairs, living room is equipped with adequate sofas and recliners for six residents, adequate outside space for rest and recreational.

Perishable and non-perishable food supply appeared adequate. Knives will be locked in the kitchen cabinet. Cleaning and Chemical supplies are kept in locked cabinet under the kitchen sink. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lightning. Mattresses and linen were in good condition. Extra linen and towels are available. Hot water temperature measured at 108 degrees F. Carbon monoxide and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid mats in place, hand soap and paper towels available for use. Trash cans with tight fitting lids are in place.

Fire extinguisher serviced on 3/4/2022. Medications and first aid kit are locked in the hallway closet. Complaint poster posted, resident council info posted, residents' rights posted, emergency disaster plan posted. Gate is self-closing and self-latching.

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: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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