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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209286
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:54:26 PM

Document Has Been Signed on 05/09/2023 02:54 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:SCHOOL HOUSE LANEFACILITY NUMBER:
157209286
ADMINISTRATOR:CU, STEPHANIE CLAIR V.FACILITY TYPE:
735
ADDRESS:7104 SCHOOL HOUSE LANETELEPHONE:
(661) 454-9324
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 0DATE:
05/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Administrator, Stephanie CuTIME COMPLETED:
12:23 PM
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Licensing Program Analyst (LPA) Darius Williams, conducted an announced Pre-licensing visit. LPA Williams met with Administrator, Stephanie Cu and discussed the purpose of the visit.

LPA Williams and the Administrator toured the facility.

The living room was clean and in good repair. There was seating available for four clients.

LPA Williams toured four bedrooms. Each bedroom had a bed, dresser, night stand, chair, required linens, working light, and enough space to accommodate people.

Bathroom was clean and in good repair. Bathroom had non-slip mats in the shower and grab bars for client use.

Chemicals were observed behind a locked cabinet door and identified medication storage.

Kitchen was clean and in good repair. Faucet water temperature reflected approximately 117 degrees Fahrenheit (F) via facility thermometer. Refrigerator reflected approximately 38 degrees F. and freezer reflected approximately 0 degrees F. Utensils, plates, and cook wear were present.

First aid kit was present and had all required items.

Smoke detector, carbon monoxide, and fire extinguisher were present and serviceable.

*LIC 809-C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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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: SCHOOL HOUSE LANE
FACILITY NUMBER: 157209286
VISIT DATE: 05/09/2023
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LPA Williams reviewed Component III with the administrator.

An exit interview was conducted and a copy of this report will be provided via e-mail.

This report will be forwarded to Central Application Bureau for further review.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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