157209299-1-31-2023-24-AS-MYAG-CNLR26-20230131113750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157209299
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:38:00 AM

Document Has Been Signed on 01/31/2023 11:38 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:	LERWICK HOME CARE		FACILITY NUMBER:	157209299
ADMINISTRATOR:	TELMO, SOCORRO ANN		FACILITY TYPE:	740
ADDRESS:	10213 LERWICK AVENUE		TELEPHONE:	(661) 665-2874
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	6	CENSUS: 5	DATE:	01/31/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Administrator Socorro Ann Telmo		TIME COMPLETED:	11:30 AM

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On 01/31/2023, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing / Component III Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry into the facility. LPA met with Administrator (ADM) Socorro Ann Telmo.

The facility is a 5 bedroom and 2-bathroom home and fire clearance was granted for 5 Non-Ambulatory and 1 Bedridden for a total capacity of 6. There are 5 residents present during this inspection. LPA toured the facility with ADM. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available. A fire extinguisher was observed and had a service date of 03/22/22. Kitchen was toured and observed to have dishes, plates, and utensils. Knives will be kept locked and secure in the kitchen shelf. Medications will be locked in kitchen cabinets. Freezer maintained at temperature 0-degree F and refrigerator maintained at temperature 37-degree F.

First aid kit was observed and contained all required items. Cleaning supplies and chemicals observed to be stored and locked in garage cabinet. Hot water temperature ranged between 114 to 119 degrees F. Bedrooms were observed to have the required furnishing and are ready for occupancy. LPA observed an extra supply of bed linens. Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching. Smoke detectors and carbon monoxide were observed to be operational during this inspection. All residents’ records reviewed to have updated emergency contact information, Pre-Admission Appraisal, Admission Agreement, and Physician Report. Staff records were reviewed to have personnel records, Criminal record clearances and current First Aid/CPR certification.

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

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued. A copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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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