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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201410
Report Date: 09/14/2022
Date Signed: 09/14/2022 01:24:04 PM

Document Has Been Signed on 09/14/2022 01:24 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:HASKINS RESIDENTIAL CAREFACILITY NUMBER:
107201410
ADMINISTRATOR:HASKINS, DONALDFACILITY TYPE:
735
ADDRESS:1037 SOUTH CHESTNUT AVENUETELEPHONE:
(559) 453-6832
CITY:FRESNOSTATE: CAZIP CODE:
93702
CAPACITY: 18CENSUS: 13DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Direct Care Staff, Sabree SwiftTIME COMPLETED:
01:33 PM
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On 09/14/2022, Licensing Program Analyst (LPA) Walton arrived unannounced and attempted to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was granted entry to the facility by Direct Care Staff, Sabree Swift.

Facility staff and LPA contacted Administrator, Natalie Haskins via telephone. Administrator did not answer. LPA left a voicemail requesting for Administrator to return the call.

LPA will return at a later date to continue the annual inspection.

Exit interview conducted. A copy of this report was discussed and provided to Direct Care Staff, Sabree Swift, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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