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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208895
Report Date: 08/27/2021
Date Signed: 08/27/2021 09:06:41 AM

Document Has Been Signed on 08/27/2021 09:06 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:SIERRA MEADOWS BEHAVIORAL HEALTHFACILITY NUMBER:
107208895
ADMINISTRATOR:TATUM, MATTHEWFACILITY TYPE:
772
ADDRESS:2343 DEAUVILLE CIRCLETELEPHONE:
(559) 593-9801
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 0DATE:
08/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Delilah Ramirez, Designated RepresentativeTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPAs) Mai Yang and Lady Cabrera conducted a LPA spoke with case management visit. LPAs met with Designated Representative Delilah Ramirez. Kristine Williams, Chief Operating Officer was available via phone.

During a complaint investigation on 4/20/2021, LPA Cabrera obtained Resident’s (R1) Admission Agreement. Per records review and observation, the facility requires to update the Admission Agreement.

Exit interview was conducted. LPA provided 809 report to Designated Representative.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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