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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206916
Report Date: 09/30/2024
Date Signed: 09/30/2024 02:13:45 PM

Document Has Been Signed on 09/30/2024 02:13 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/
DIRECTOR:		DIANNA L ELLISFACILITY TYPE:
740
ADDRESS:11910 CROCKETT COURTTELEPHONE:
(661) 587-1191
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 6DATE:
09/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Margaret GardeaTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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On 9/0/24, Licensing Program Analysts (LPAs) M. Medina and S. Salazar conducted an unannounced Annual Required Continuation visit to facility. LPAs introduced self, stated purpose of visit and allowed entrance by Direct Care Staff. LPAs met with House Manager, Margaret Gardea to conduct visit.

LPAs reviewed a sample of resident files including home health and Hospice care plans were observed. A sample of staff files were reviewed and observed to have the required documentation. LPAs interviewed staff and resident. Inspection tool completed.

Exit interview conducted with Administrator. A copy of this report was provided at the time of visit.

No deficiencies cited.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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