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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206803
Report Date: 08/19/2022
Date Signed: 08/19/2022 02:03:19 PM


Document Has Been Signed on 08/19/2022 02:03 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:STEPHEN HOUSEFACILITY NUMBER:
107206803
ADMINISTRATOR:SUNDARI SUSAN KENDAKURFACILITY TYPE:
740
ADDRESS:1824 DONNER AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
08/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator Sundari Susan Kendakur and Shannon Steele Care Coordinator TIME COMPLETED:
01:00 PM
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On 8/19/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a Case Management inspection. LPA introduced self, stated the purpose of the visit and met with Administrator Sundari Susan Kendakur and Shannon Steele Care Coordinator (CC).

The purpose of today's inspection is to address the facility's failure to submit Incident Report to the Fresno Community Care Licensing (CCL) office on incident that occurred on 07/15/22. Administrator and CC stated incident report was faxed on 07/15/22 but no confirmation was provided on facility report. Facility office staff dropped off incident report after no confirmation received on 07/28/22.

No deficiencies issued.

An exit interview was conducted. LPA discussed with Administrator plan to ensure incident report are confirmed received by CCL. A copy of this report will be provided via email to Administrator and an electronic read receipt confirms receiving these documents. Signed report on file.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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