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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209285
Report Date: 03/01/2023
Date Signed: 03/06/2023 09:45:45 AM


Document Has Been Signed on 03/06/2023 09:45 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:TEDENEK ELDER HOME 2FACILITY NUMBER:
157209285
ADMINISTRATOR:TUSAW, MYATFACILITY TYPE:
740
ADDRESS:13001 BIRKENFELD AVETELEPHONE:
(661) 205-1787
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 0DATE:
03/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Licensee, Shemeles Kabteneh and Administrator, Myat TusawTIME COMPLETED:
11:25 AM
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On 03/01/2023, Licensing Program Analyst (LPA) A. Walton conducted an announced Pre-Licensing / Component III inspection. LPA Walton introduced self, stated purpose of visit, and was allowed entry into the facility. LPA met with Licensee, Shemeles Kabteneh and Administrator, Myat Tusaw.

The facility is a four bedroom and two bathroom home. Fire clearance was granted for five non-ambulatory and one bedridden, for a total of six capacity.

LPA toured the facility. Common areas were furnished and had adequate seating and lighting available. Bedrooms had required furnishings and are ready for occupancy. Hot water measured at 124 degrees F in bathroom 1 and 123.9 degrees F in bathroom 2. LPA observed an extra supply of bed linens and personal hygiene products. Kitchen was toured and observed to have dishes, plates, and utensils. Cleaning supplies and chemicals were observed in a locked cabinet under the kitchen sink and in the laundry room. Medications will be locked in a cabinet in the laundry room. A fire extinguisher was observed and has a service date of 04/19/2022. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching.

Component III was conducted during today’s pre-licensing visit.

LPA is requesting that the Administrator bring the hot water temperature in range between 105 - 120 degrees F in bathroom 1 and bathroom 2.

LPA will notify CAB that facility is ready to be licensed once the above information has been received.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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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