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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209322
Report Date: 05/02/2024
Date Signed: 05/16/2024 10:27:52 AM

Document Has Been Signed on 05/16/2024 10:27 AM - 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 RETREAT #3FACILITY NUMBER:
157209322
ADMINISTRATOR/
DIRECTOR:		DILLARD, SHEILAFACILITY TYPE:
740
ADDRESS:4825 KENNY STREETTELEPHONE:
(661) 213-6798
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: 0DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Sheila Dillard, Licensee/AdminstratorTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Lissett Padgett arrived announced to conduct the Annual inspection. LPA met with Administrator Sheila Dillard (AD) and explained the purpose of the visit. Facility was toured with AD. Currently there are no residents living in this home.

During this visit, LPA toured the facility inside & out. Facility has 3 Resident bedrooms and two bathrooms.
Facility observed to be clean, odor free and at a comfortable temperature, 70 degrees per hallway thermostat. Common areas were furnished well with adequate seating and lighting available. Living room has sectional, with sufficient seating for 6 residents. Fireplace observed clean and AD explained that it is inoperable and will not be used. Dining room has dining table and chairs sufficient for 6.

LPA observed an adequate supply of linen in hallway closet. Combo Alarm for Carbon Monoxide and smoke detection in the entryway tested and found to be operational. Resident bathroom is properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mat, paper towels were observed. Hot water measured 116.6 degrees F.

Bedrooms appeared clean and contained mattresses and bedding in good condition. Lighting was appropriate. All bedrooms are set up to be shared by two residents. Smoke detectors in bedrooms were tested and found to be operational. Windows are operable with screens in good condition.
Bathroom in Bedroom 3 is allocated for staff. This bathroom does not have grab bars in toilet or shower/tub areas. Hot water measured 118.8 degrees F.

Extra resident hygiene supplies are stored in entry way closet. This closet is kept locked and also contains cleaning supplies and will store resident medications. AD has individual bins allocated for residents and a small locked box for refrigerated medications. Knives are stored in this closet. First aid kit reviewed and found to contain required items.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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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: AAA RESIDENTIAL ELDERLY RETREAT #3
FACILITY NUMBER: 157209322
VISIT DATE: 05/02/2024
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LPA observed that the kitchen was well maintained, with working lights and well maintained appliances. The kitchen counters and sink are free from debris. LPA observed a trash bin with the lid in cabinet. LPA observed refrigerator/freezer are well maintained and clean. LPA observed a 2 day perishable food supply. The kitchen pantry was clean, organized, and had 7 days of non-perishable food. A fire extinguisher is mounted on the wall with the correct pressure gauge as indicated on the meter. LPA observed required paper products.

LPA, observed that the backyard is well maintained, bushes and grass in good condition. Facility has covered patio with table and chairs for 6. Doors and passageways are unobstructed throughout the facility including outdoors. Self latching gate on the side of the yard was found to be in working order.

Smoke and Carbon Monoxide detectors tested and found to be functioning. LPA conducted staff file reviews. Administrator’s re-certification was confirmed to be in active status and was received by the Department as required.

An exit interview was conducted. A copy of this report provided to AD, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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