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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209285
Report Date: 01/31/2025
Date Signed: 01/31/2025 07:30:01 PM

Document Has Been Signed on 01/31/2025 07:30 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:TEDENEK ELDER HOME 2FACILITY NUMBER:
157209285
ADMINISTRATOR/
DIRECTOR:		KABTENEH, SHEMELESFACILITY TYPE:
740
ADDRESS:13001 BIRKENFELD AVETELEPHONE:
(661) 205-1787
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 4DATE:
01/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:LIcensee: Shemeles KabtenehTIME VISIT/
INSPECTION COMPLETED:
07:45 PM
NARRATIVE
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On 1/31/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greet by Staff (S1) Yuliana Yap, LPA was granted entry. 4 residents were present during inspection. Licensee (A1) Shemeles Kabteneh arrived shortly after LPA’s arrival.

LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. A sample of resident’s medications were checked and observed kept locked in medication cabinet. Clients’ MARS was reviewed. Morphine Sulfate 20 MG/1ML SOL .25 ML (5MG) by mouth or under the tongue every 1 hour as needed for pain or shortness of breath was observed in the refrigerator unlocked and accessible. Fire extinguisher reviewed with a service date of: 3/1/24. Fire drill not completed and no record observed in facility. Cleaning chemicals was observed stored and locked in facility cabinet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 113.9 to 116.7 degrees in 2 bathrooms.

Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. No thermometers observed in freezer or refrigerator, therefore no temperature was recorded during visit. Carbon monoxide were tested and observed to be operational. All clients’ files reviewed. 2 out of 4 residents is missing Consent for Medical treatment form. 3 out of 4 residents are missing the Appraisal Needs and Services form. 3 out of 4 residents are missing the Safeguard for Property Values form. All staff files were reviewed. Licensee is missing LIC-501 or Employee/License application, Medication Completion Certificate and a written copy of completed education.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: TEDENEK ELDER HOME 2
FACILITY NUMBER: 157209285
VISIT DATE: 01/31/2025
NARRATIVE
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The following deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 2/14/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance-RCFE, Emergency and Disaster Plan (LIC 610E -RCFE), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A- RCFE)

A copy of this report and appeal rights was provided to L1, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 01/31/2025 07:30 PM - It Cannot Be Edited


Created By: Jacques Leffall On 01/31/2025 at 06:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TEDENEK ELDER HOME 2
FACILITY NUMBER: 157209285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.153(d)
Licensing
(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 3 out of 4 forms of resident's Safegaurd for Property Values missing in resident's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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Licensee agrees to submit copies of completed Safeguard for Property Values to Fresno CCL by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/31/2025 07:30 PM - It Cannot Be Edited


Created By: Jacques Leffall On 01/31/2025 at 06:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TEDENEK ELDER HOME 2
FACILITY NUMBER: 157209285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 LIC-501 or Licensee Application missing in Licensee files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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Licensee agrees to submit copies of completed LIC-501 or copy of completed Licensee application to Fresno CCL by POC date.
Type A
Section Cited
CCR
87405(d)(6)
Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (6) Have a high school diploma or equivalent, such as a General Education Development (GED) certificate.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 Licensee's proof of completed education missing in Licensee's file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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Licensee agrees to submit a copy of completed education to Fresno CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/31/2025 07:30 PM - It Cannot Be Edited


Created By: Jacques Leffall On 01/31/2025 at 06:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TEDENEK ELDER HOME 2
FACILITY NUMBER: 157209285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87406(a)(1)(B)
Administrator Certification Requirements
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. (1) Applicants who possess a valid Nursing Home Administrator license, issued by the California Department of Public Health, shall be exempt from completing an approved Initial Certification Training Program and taking a written exam, provided the individual completes twelve (12) hours of classroom instruction in the following Core of Knowledge areas: (B) Four (4) hours of instruction in medication management, including the use, misuse, and interaction of drugs commonly used by the elderly, including antipsychotics, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 certificate of completed medication training missing from Licensee's file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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Licensee agrees to submit a copy of completed medication training certificate to Fresno CCL by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 01/31/2025 07:30 PM - It Cannot Be Edited


Created By: Jacques Leffall On 01/31/2025 at 06:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TEDENEK ELDER HOME 2
FACILITY NUMBER: 157209285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(21)
General Food Service Requirements
(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 thermometers not observed in refrigerator and freezer, thus unable to obtain temperatures in refrigerator and freezer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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Licensee agrees to submit receipts of purchased thermometers and photos of thermometers to Fresno CCL by POC due date.
Type A
Section Cited
CCR
87465(h)(1)(A)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, ,record review, the licensee did not comply with the section cited above in 1 out of 1 medication Morphine Sulf 20 mg/1ml give .25ml by mouth or under tongue every hour as needed for pain or shorntess of breath was observed unlocked in refriderator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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Licensee agrees to have all staff complete medication training. Licensee agrees to submit copies of completed medication training to Fresno CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 01/31/2025 07:30 PM - It Cannot Be Edited


Created By: Jacques Leffall On 01/31/2025 at 06:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TEDENEK ELDER HOME 2
FACILITY NUMBER: 157209285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 3 out of 4 residents are missing Safegaurd for Property Values in resident's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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LIcensee agrees to complete 3 Safeguard for Property Values forms for missing residents and submit copies of completed forms to Fresno CCL by POC due date.
Type A
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 3 out of 4 residents Appraisal for Needs and services missing in resident's files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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LIcensee agrees to complete 3 Safeguard for Appraisal Needs and Services for missing residents and submit copies of completed forms to Fresno CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 01/31/2025 07:30 PM - It Cannot Be Edited


Created By: Jacques Leffall On 01/31/2025 at 06:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TEDENEK ELDER HOME 2
FACILITY NUMBER: 157209285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 completed fire drill and Fire Drill log missing in faciliyt which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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Licensee agrees to complete fire drill in facility and submit copy of completed fire drill log to Fresno CCL by POC due date.
Type A
Section Cited
CCR
87469(a)
Advance Directives and Requests Regarding Resuscitative Measures
(a) Upon admission, a facility shall provide each resident, and representative or responsible person of each resident, with written information about the right to make decisions concerning medical care. This information shall include, but not be limited to, the Department's approved brochure entitled “Your Right To Make Decisions About Medical Treatment,” PUB 325, (3/12) and a copy of Sections 87469(b), (c) and (d) of the regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 4 Consent for Medical Treatment forms missing from resident files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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2
3
4
Licensee agrees to complete 3 Consent for Medical Treatment forms and submit copies of completed forms to Fresno CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
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