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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103810105
Report Date: 08/24/2020
Date Signed: 08/24/2020 02:43:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:JACK & JILL'S EARLY CHILD DEVELOPMENT CENTER, INCFACILITY NUMBER:
103810105
ADMINISTRATOR:GRAVES, EARLINE EVETTEFACILITY TYPE:
840
ADDRESS:969 S WILLOW AVETELEPHONE:
(559) 255-8817
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:55CENSUS: 13DATE:
08/24/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Earline GravesTIME COMPLETED:
12:45 PM
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On 08/24/2020, Licensing Program Analyst (LPA) Juvenal Moctezuma conducted an unannounced Case Management inspection. LPA met with Licensee, Earline Graves. The purpose of this visit is to sign documents. Due to a consistency check during visit made on 08/22/2020, see LIC809 and LIC809C. On this date the system went into a consistency check and LPA was unable to print this report or obtain signatures. Notice of Site Visit was Posted.

No deficiencies cited during today's visit.
A COPY OF THIS REPORT IS TO REMAIN IN THE FACILITY FOR PUBLIC REVIEW.
THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
To order forms, etc. visit our website at www.ccld.ca.gov
SUPERVISOR'S NAME: Michael DuarteTELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Juvenal MoctezumaTELEPHONE: (559) 580-0275
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2020
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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