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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201578
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:39:25 PM


Document Has Been Signed on 08/19/2022 03:39 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:WILLIAMS WHITTLE RESIDENTIAL CARE HOME #3FACILITY NUMBER:
107201578
ADMINISTRATOR:WHITTLE, CHERYL AFACILITY TYPE:
740
ADDRESS:4093 W. TERRACE AVENUETELEPHONE:
(559) 271-2152
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 3DATE:
08/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Lucille WilliamsTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Katie Brown conducted a Case Management in conjunction with am Annual Inspection. LPA met with and explained the purpose of the Case Management with Lucille Williams.


The purpose of the Case Management is to follow up on a Special Incident Report (SIR) submitted by the facility which occurred on 6/18/2022.

There were no citations issued during this Case Management








An exit interview was conducted and a copy of this report was provided to Lucille Williams, whose signature on this form confirms receipt of these documents.


LPA requested the following updated forms be submitted to CCL by 7/27/22: LIC 308, LIC 309, LIC 500, LIC 610E, LIC9020, Current Liability Insurance, Administrator’s Certificate.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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