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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202532
Report Date: 08/09/2021
Date Signed: 08/09/2021 08:53:56 AM

Document Has Been Signed on 08/09/2021 08:53 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:KERN TRANSITION HOME-RIVER GLENFACILITY NUMBER:
157202532
ADMINISTRATOR:GONZALEZ, TIFFANYFACILITY TYPE:
735
ADDRESS:4409 RIVER GLEN DRIVETELEPHONE:
(661) 213-3800
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 4CENSUS: 4DATE:
08/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Cargeiver, Jose Garza and House Manager, Antwanique WalkerTIME COMPLETED:
08:55 AM
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On 08/09/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct a Case Management visit. LPA introduced self and was granted entry to the facility. LPA requested to speak with Administrator. Caregiver, Jose Garza contacted House Manager, Antwanique Walker. LPA spoke with House Manager via telephone. LPA disclosed the purpose of the visit with House Manager.

The purpose of today's visit is to follow up on an Incident Report that was reported to the Fresno CCL office on 08/06/2021. LPA is requesting the following documents be submitted to the Fresno CCL office by 08/10/2021: Resident Roster, Personnel Report, staff file for S1, resident file for R1, staff schedule for July 2021 and August 2021, and staff contact information.

No deficiencies issued during this visit.

Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2021
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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