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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208808
Report Date: 06/16/2023
Date Signed: 06/16/2023 11:27:09 AM


Document Has Been Signed on 06/16/2023 11:27 AM - 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:MRS SCOTT'S WHERE THE HEART IS HOMES-YOSEMITEFACILITY NUMBER:
107208808
ADMINISTRATOR:BRICE, NASTASSHAFACILITY TYPE:
740
ADDRESS:425 W KELLY AVENUETELEPHONE:
(559) 298-7975
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
06/16/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Administrator, Nastassha BriceTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Plan of Correction (POC) visit in regards to complaint #24-AS-20230509103411. LPA Williams met with Administrator Nastassha Brice and discussed the purpose of the visit.

Administrator reported she has not provided a refund to Resident 1's authorized representative at this time as the Administrator is awaiting for second payroll to occur to budget in the finances. Administrator reported she could possibly have the payment by 7/5/2023.

Deficiency was not corrected by Plan of Correction due date of 6/15/2023. A civil penalty assessment of $100 is being assessed on 6/16/2023, in regards to deficiency issued on 6/1/2023 complaint control #24-AS-2-230509103411.

An exit interview was conducted and a copy of this report will be provided via e-mail.



SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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