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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209103
Report Date: 10/15/2024
Date Signed: 10/21/2024 04:38:43 PM

Document Has Been Signed on 10/21/2024 04:38 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AAA RESIDENTIAL ELDERLY RETREATFACILITY NUMBER:
157209103
ADMINISTRATOR/
DIRECTOR:		BELL, ALEXIS EFACILITY TYPE:
740
ADDRESS:4313 MONITOR STREETTELEPHONE:
(661) 213-6798
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: 5DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Alexis Bell, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 10/15/24, Licensing Program Analyst (LPA) R. Bruce arrived unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry by Direct Care Staff Gwen Bonner. Staff contacted Administrator, Alexis Bell who arrived shortly thereafter.

Facility has one entrance/exit point. Facility appeared clean with no obvious obstruction or fire clearance issues. Tour of facility was provided by Gwen Bonner. Bedrooms were clean and furnished per regulation. Sharp items were locked in kitchen cabinet. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. There is a locked shed in the backyard which holds a large supply of non-perishable food. Two additional locked sheds are located in the backyard which store office supplies and various equipment. There are three freezers located on the back patio. Two are not completely functioning and will be repaired or removed. Currently the facility dryer is located in the den and clothes are being dried by hanging outside. Dryer has been serviced and when part comes in will be moved back to wash room. Medications observed locked in hallway closet. LPA reviewed all 4 resident's Centrally Stored Medication list, MARS and medication. No regulation violations were noted. Fire extinguisher purchased today and is located in the kitchen. LPA toured bathrooms. Water registered at 105 degrees. Personal hygiene items are locked in hall closet. Bathroom trash bins were observed lids. Securely fastened grab bars observed in bathroom along with no slip bath mats. Resident rooms toured and observed to be adequately furnished and lit. A tour of the exterior was conducted. No issues noted. Four staff records were reviewed as well as three resident files and all were found to contain required documentation.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/01/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator


Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and
Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site and copy will be provided by email as printer is not working.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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