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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209285
Report Date: 03/18/2024
Date Signed: 03/18/2024 12:45:33 PM


Document Has Been Signed on 03/18/2024 12:45 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:TEDENEK ELDER HOME 2FACILITY NUMBER:
157209285
ADMINISTRATOR:KABTENEH, SHEMELESFACILITY TYPE:
740
ADDRESS:13001 BIRKENFELD AVETELEPHONE:
(661) 205-1787
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 3DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Administrator, Shemeles KabtenehTIME COMPLETED:
01:04 PM
NARRATIVE
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On 03/18/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Shemeles Kabteneh, via telephone. Administrator arrived a short time later.

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 securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 117.1 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable 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 serviced on 04/03/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. The date of the last fire drill was not documented. All cleaning supplies are locked and inaccessible. LPA reviewed staff and client records. Upon review of records, LPA found that 3 out of 3 residents did not have a complete resident file. 2 out of 2 residents receiving hospice services did not have a hospice care plan on file. Staff records were observed to be complete with 1st Aid/CPR and health screen. Medications reviewed and observed to have original labels and be administered as prescribed. First Aid Kit contained the required supplies.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/01/2024: 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.

Exit interview conducted and plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Shemeles Kabteneh, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


Document Has Been Signed on 03/18/2024 12:45 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: TEDENEK ELDER HOME 2
FACILITY NUMBER: 157209285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 3 out of 3 residents in care did not have a complete resident record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
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Licensee agrees to review section 87506 and submit a written statement detailing the steps the facility will take to ensure the requirements for section 87506 are met to the Fresno CCL office by the POC due date.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 2 out of 2 hospice residents did not have a current and complete hospice care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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Licensee agrees to obtain a complete and current hospice care plans for each residents and submit a copy of the care plan to the Fresno CCL office by the POC due date.
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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