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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203307
Report Date: 04/01/2022
Date Signed: 04/01/2022 03:31:38 PM

Document Has Been Signed on 04/01/2022 03:31 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:
107203307
ADMINISTRATOR:HEKIMIAN, VARTANFACILITY TYPE:
735
ADDRESS:6101 N. MITRE AVENUETELEPHONE:
(559) 271-4572
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 5DATE:
04/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Vivian FowlerTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management visit. LPA met with and explained the purpose of the visit with Administrator Vivian Fowler.

The purpose of the visit it to conduct Case Management follow up on Special Incident Report (SIR) that was submitted by the facility which resulted in a resident AWOL. The facility also verbally reported the incident to LPA.

LPA observed R1’s room to find a window alarm in place and in working order. LPA conducted a review of R1’s file. LPA interviewed AD.



No deficiencies cited during this Case Management visit.



A copy of this report was provided via email to Vartan@amvacorp.com, and an exit interview was conducted
with AD.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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