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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206924
Report Date: 04/06/2021
Date Signed: 04/06/2021 03:14:21 PM

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:SHAEMAR RESIDENTIAL CARE IIFACILITY NUMBER:
107206924
ADMINISTRATOR:RONALD & MARCELIA WORTHLEYFACILITY TYPE:
740
ADDRESS:6123 N. 10TH STREETTELEPHONE:
(559) 451-0108
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 0DATE:
04/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:N/ATIME COMPLETED:
02:15 PM
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Licensing Program Manager I (LPM I) Sergiy Pidgirny and Licensing Program Analyst (LPA) Lady Cabrera conducted a health and safety check prior to the forfeiture of the license with intent to do final inspection. Upon arrival, facility appeared to be vacant. LPM I and LPA rang the doorbell, and there was no response. LPM I and LPA were unable to gained access to the facility.

LPA verified all residents have been safely relocated to a different license facility.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
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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