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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202497
Report Date: 12/16/2021
Date Signed: 04/26/2022 10:44:00 AM


Document Has Been Signed on 04/26/2022 10:44 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/26/2022 10:42 AM

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

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This is an amended report.

On 12/16/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct a POC visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Eddie Rangel.

On 11/03/2021, LPA delivered findings for complaint number 24-AS-20210709101540. Facility was issued a citation with a Plan of Correction (POC) due date of 12/03/2021. Administrator agreed to to provide proof of a refund for the Medication Program Fees and Care Charges accrued during R1's absence and provide a detailed billing statement that includes details of charges and credits for R1 to the Fresno CCL office by the due date. As of 12/16/2021, LPA has not received documentation.

Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site by facility representative.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021
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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