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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209406
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:22:26 PM

Document Has Been Signed on 01/16/2024 02:22 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 #4FACILITY NUMBER:
157209406
ADMINISTRATOR:DILLARD, SHEILAFACILITY TYPE:
740
ADDRESS:10615 POLO GLEN DRIVETELEPHONE:
(661) 213-6798
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 0DATE:
01/16/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Sheila DillardTIME COMPLETED:
02:35 PM
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On 1/16/23, Licensing Program Analyst (LPA) M. Medina conducted an announced Pre-licensing inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensees, Sheila Dillard. LPA toured the facility with Licensee. The facility is 4 bedrooms and 3 bathrooms home. Fire clearance was granted for 6 non-ambulatory residents.

Common areas were furnished and had adequate seating and lighting available. All bedrooms were observed to have required furnishings. Kitchen was toured and observed to have dishes, plate, and utensils. Facility has 7-day supply of non-perishable food available as of date of inspection. Resident bathrooms have grab bars in the shower and toilet areas, and a non-skid mat available. Knives and medication will be locked and secured in hall closet. Cleaning supplies and chemicals will be locked and secured in laundry room. Fire extinguisher present with a purchase date of 9/01/23 . Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. Water temperature measured at 110 degrees F. Facility has a working telephone of (661) 213-3926.

Outside of facility toured. Exits open free of obstruction. Pool is surrounded by a locked and secured gate and inaccessible to residents.

Component III conducted during pre-licensing inspection.

LPA found that applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.



Exit interview conducted. A copy of this report was provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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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