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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206916
Report Date: 09/15/2023
Date Signed: 09/15/2023 12:13:26 PM

Document Has Been Signed on 09/15/2023 12:13 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:VILLAGE GARDENSFACILITY NUMBER:
157206916
ADMINISTRATOR:DIANNA L ELLISFACILITY TYPE:
740
ADDRESS:11910 CROCKETT COURTTELEPHONE:
(661) 587-1191
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 5DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Diana EllisTIME COMPLETED:
12:20 PM
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On 9/15/23, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit and allowed entrance into facility. Administrator, Diana Ellis present to conduct facility visit.

Currently, five (5) residents in care. Residents were all present during today's inspection. Residents were observed to be relaxing in the family room, resting in their bedroom, and preparing for their meal.

Facility tour began in resident bedrooms. All bedrooms have required furnishings, linens observed to be clean and in good repair. Resident bathrooms toured. Fixtures observed to be clean and operational during inspection. All common area have adequate seating and lighting to meet the needs of residents. Kitchen tour conducted, a 2-day supply of perishable and a 7-day supply of non-perishable food present and properly stored. All knives are stored and secured in cabinet in laundry room. Medications observed to be locked and secured in cabinet

All cleaning supplies are locked and secured and inaccessible to residents. Fire extinguisher present with a purchase date of 12/01/2022. Last fire drill conducted on 8/07/23 according to facility records.

Outside of the facility toured and no hazards were observed. Pool observed to be locked and secured and inaccessible to residents. All exits open freely without obstruction.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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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