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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202517
Report Date: 02/16/2022
Date Signed: 02/16/2022 07:22:33 PM


Document Has Been Signed on 02/16/2022 07:22 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:V&A ASSISTED LIVINGFACILITY NUMBER:
107202517
ADMINISTRATOR:RODRIGUEZ, GEORGEFACILITY TYPE:
735
ADDRESS:11140 S. CHERRY AVETELEPHONE:
(559) 864-9873
CITY:FRESNOSTATE: CAZIP CODE:
93725
CAPACITY:4CENSUS: 4DATE:
02/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Staff Michael Callahan and Administrator George RodriguezTIME COMPLETED:
11:45 AM
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Licensing Program Analysts Shawna Doucette and Katie Brown arrived at the facility unannounced to conduct a Case Management Inspection for a Case Management that occurred on 09/28/21 to follow up on a CPI hold. Staff Michael Callahan took Covid 19 pre cautionaries prior to entry into the facility. Administrator George Rodiriguez responded to the facility to assist with the visit.

LPA Shawna Doucette reviewed Staff records for CPI training.

No deficiencies observed.

An exit interview was conducted with Administrator George Rodriguez and a copy of this report was emailed to Vartan Hekimian.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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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