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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209406
Report Date: 01/23/2025
Date Signed: 01/23/2025 11:27:43 AM

Document Has Been Signed on 01/23/2025 11:27 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AAA RESIDENTIAL ELDERLY RETREAT #4FACILITY NUMBER:
157209406
ADMINISTRATOR/
DIRECTOR:		DILLARD, SHEILAFACILITY TYPE:
740
ADDRESS:10615 POLO GLEN DRIVETELEPHONE:
(661) 213-6798
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 0DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Sheila DillardTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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On 1/23/2025, Licensing Program Analyst (LPA) M. Medina conducted an Annual/Required visit. LPA met with Licensee/Administrator, Sheila Dillard to conduct facility inspection.

Facility was licensed in January 2024 and has had no residents in care. Facility tour conducted, facility observed to be clean, odor free and a comfortable temperature. Residents bedrooms are fully furnished with required accommodations. Adequate seating and lighting observed in both the living room, and dining room. Client bathrooms toured, fixtures observed operational, shower has grab bars, non-skid and shower chair available. Water temperature measured at 115 degrees F. Kitchen toured, LPA observed a 7-day supply of non-perishable food. Medications and sharps will be locked and secured in hallway closet. First aid kit present with all required items.

Smoke detectors and carbon monoxide observed to be operational during today's inspection. Fire extinguisher present with a purchase date of 10/15/2024.

Outside of facility toured. Pool is surrounded by gate that is locked, secured, and inaccessible to residents. All exits open free of obstruction, no hazards observed.

No deficiencies cited during today's visit. Exit interview conducted and a copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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