157209322-6-5-2025-24-AS-RABE-DHCQ2J-20250605114713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157209322
Report Date: 06/05/2025
Date Signed: 06/05/2025 11:47:36 AM

Document Has Been Signed on 06/05/2025 11:47 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 #3		FACILITY NUMBER:	157209322
ADMINISTRATOR/ DIRECTOR:	DILLARD, SHEILA		FACILITY TYPE:	740
ADDRESS:	4825 KENNY STREET		TELEPHONE:	(661) 412-7266
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93307
CAPACITY: 6		CENSUS: 2	DATE:	06/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Sheila Dillard, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rachel Bruce 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 two residents living in this home, one was present and one was at day program. 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. Common areas were furnished well with adequate seating and lighting available. Living room has sufficient seating for 6 residents. Fireplace observed clean and properly covered with glass covering. AD explained that it is inoperable and is not being 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 and bedrooms 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 105.7 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. At the time of the inspection two bedrooms had only one bed to potentially accommodate a hospital bed should an incoming resident have one. 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.

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 06/05/2025

NARRATIVE

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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. 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. Receipt of purchase accessible and checked by LPA.

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 need of adjustment.

LPA conducted staff file and resident file reviews. Required documentation present and organized.

No citations issued at today's visit. An exit interview was conducted. A copy of this report provided to AD, whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC809 (FAS) - (06/04)

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