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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209322
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:56:14 PM

Document Has Been Signed on 10/15/2024 03:56 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 RETREAT #3FACILITY NUMBER:
157209322
ADMINISTRATOR/
DIRECTOR:		DILLARD, SHEILAFACILITY TYPE:
740
ADDRESS:4825 KENNY STREETTELEPHONE:
(661) 412-7266
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: DATE:
10/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Alexis Bell, Administrator of AAA Residential TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 10/15/2024, Licensing Program Analyst (LPA) R Bruce conducted a Case Management visit. This visit was conducted at the AAA Residential Elderly Retreat on Monitor Ave as LPA was meeting with Administrator and conducted inspection. LPA explained the purpose of the case management was to discuss recent Incident Reports (IR) submitted to CCL.

LPA reviewed and discussed IR dated 9/27/24 regarding a decline in health for resident R1. An updated incident report will be submitted informing CCL that the resident has returned home. He has been provided a hospital bed and a request for home health services. Staff will continue to monitor.

LPA reviewed and discussed IR dated 9/22/24 regarding Resident R2. R2 had been to the hospital to be treated for an infection on his arms and legs. LPA was told that the Resident has very poor hygiene and as a result of that his extremities had become infected. Staff continues to encourage him regarding hygiene practices.

No deficiencies cited during visit.
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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