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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209322
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:14:39 PM

Document Has Been Signed on 10/03/2024 12:14 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:AAA RESIDENTIAL ELDERLY RETREAT #3FACILITY NUMBER:
157209322
ADMINISTRATOR/
DIRECTOR:		DILLARD, SHEILAFACILITY TYPE:
740
ADDRESS:4825 KENNY STREETTELEPHONE:
(661) 412-7266
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: 5DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:36 AM
MET WITH:Sheila DiillardTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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On 10/03/2024, Licensing Program Analysts (LPAs) M. Medina and R. Bruce conducted an unannounced Case Management visit. LPAs introduced self, stated purpose of visit, and allowed entrance by Licensee, Sheila Dillard.

LPAs conducted visit to follow up on incident reports that were submitted to this department. An incident report for R1 which occurred on 9/19/24 for R2 which occurred on 9/24/24.

LPAs reviewed resident files and requested the following documents for both R1 and R2: Physician's report and Appraisal/Needs and Services Plan and hospital discharge paperwork.

No deficiencies cited during visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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