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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500318152
Report Date: 09/29/2020
Date Signed: 09/29/2020 11:51:13 AM

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:WILLIAMS, PATTIFACILITY NUMBER:
500318152
ADMINISTRATOR:WILLIAMS, CLAUDE/PATRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 521-5889
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:14CENSUS: 11DATE:
09/29/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Patti WilliamsTIME COMPLETED:
12:45 PM
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LPA Claudia Henley conducted a plan of correction visit today. I was met by licensee and her assistant. LPA inspected the areas needed for correction. LPA observed a working fire extinguisher, carbon monoxide detector and working smoke alarm. In the area of the storage room and restroom area, the items that needed correction have been removed. Licensee has completed all of the paperwork on the children's files that was missing licensing documents and forms. The POC's are cleared as of 9/29/2020.

No deficiencies cited during this visit.

Exit interview was conducted with licensee.
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2020
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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