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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206669
Report Date: 12/06/2022
Date Signed: 12/06/2022 01:18:01 PM

Document Has Been Signed on 12/06/2022 01:18 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:MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCEFACILITY NUMBER:
107206669
ADMINISTRATOR:MEDINA, MYSTI & ARMANDOFACILITY TYPE:
735
ADDRESS:1354 RAMONA AVE.TELEPHONE:
(559) 292-4183
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 0DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:UnavailableTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) L. Cabrera attempted visit at facility. No one answered at the door nor did LPA hear any movement inside. LPA called the facility phone number and there was no answer. LPA contacted Administrator Mysti Medina via phone and reported she was not in the state and was unavailable. Administrator reported there was no clients nor staff at the facility at this time.

Another attempt will be conducted at a later time.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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