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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206916
Report Date: 10/21/2023
Date Signed: 10/21/2023 01:18:41 PM

Document Has Been Signed on 10/21/2023 01:18 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:
10/21/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Linda Boden
Diana Ellis		TIME COMPLETED:
01:15 PM
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On 10/21/23, Licensing Program Analysts (LPA) M. Medina conducted a Case Management visit. LPA introduced self, stated purpose of visit and allowed entrance by Direct Care Staff.

Direct Staff contacted Administrator, Diana Ellis and Licensee, Linda Boden by telephone who arrived a short time later to conduct facility visit.

Facility tour conducted. Currently five residents in care. One resident is receiving hospice services and one resident is currently receiving treatment at Adventist Bakersfield Hospital.

Outside of facility toured. Pool is surrounded by fence and observed to be locked and secured. All exits open free of obstruction. No hazards observed.

No deficiencies observed or cited during visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2023
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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