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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400544
Report Date: 10/05/2020
Date Signed: 10/05/2020 04:52:20 PM

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:TERRACES AT SAN JOAQUIN GARDENS, THEFACILITY NUMBER:
100400544
ADMINISTRATOR:LOPEZ, JESSICAFACILITY TYPE:
741
ADDRESS:5555 NORTH FRESNO STREETTELEPHONE:
(559) 439-4770
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:652CENSUS: 362DATE:
10/05/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jessica Lopez, AdministratorTIME COMPLETED:
03:06 PM
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Licensing Program Manager I (LPM) Sergiy Pidgirny and Licensing Program Analyst (LPA) Lady Cabrera contacted Administrator Jessica Lopez via telephone..

The purpose of the case management phone call is to follow-up on the LIC 624 Unusual Incident/Injury Report and LIC 624A and to obtain additional information. The incident occurred on 09/25/2020 and it was reported to Community Care Licensing on 09/29/2020.

Requested documents to submit to CCLD:



1. CCRC Agreement
2. Progress notes
3. Most recent medical assessment

The above documents shall be submitted to CCLD by 10/08/2020 (COB)

The original LIC809 will be emailed to Jessica Lopez at Jessica.Lopez@HumanGood.org
with intent to obtain a signature. The report will be signed and submitted to CCLD by 10/06/2020.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020
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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