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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206800
Report Date: 10/29/2021
Date Signed: 10/29/2021 02:36:23 PM

Document Has Been Signed on 10/29/2021 02:36 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:JAY HOMES INC SANGERFACILITY NUMBER:
107206800
ADMINISTRATOR:RICHARDSON, MARYFACILITY TYPE:
735
ADDRESS:698 S DOCKERYTELEPHONE:
(559) 286-6701
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY: 6CENSUS: 6DATE:
10/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Assistant Administrator Candis FulmerTIME COMPLETED:
02:45 PM
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A Case Management visit was conducted on the dates & during the times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Assistant Administrator (AA) Candis Fulmer & stated purpose of visit.

The purpose of this visit was to verify that Person 1 (P1) with a Decision & Order excluding P1 from working &/or being on the premises of this facility,was no longer working &/or present at this facility

During this visit it was confirmed that P1 had not & was not working or on the premises of this facility. P1 never worked at this location & gave notice to Licensee at beginning of 2021.

No deficiencies issued. Exit interview conducted with AA. Report provided.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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