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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208896
Report Date: 12/20/2021
Date Signed: 12/20/2021 10:35:17 AM

Document Has Been Signed on 12/20/2021 10:35 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:OASIS/PALSFACILITY NUMBER:
107208896
ADMINISTRATOR:DIBUDUO, MICHELLEFACILITY TYPE:
775
ADDRESS:5377 N FRESNO STTELEPHONE:
(559) 224-9121
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 30CENSUS: 0DATE:
12/20/2021
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Michelle Dibudo, AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Lady Cabrera arrived announced for an Annual Required Inspection. At this time facility is temporarily closed and have no clients. LPA met with Administrator and stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place.

Facility appeared cleaned with no obstruction or fire clearance issues. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathroom sink.

Facility provides snacks for clients. Facility has cleaning and PPE supplies. Facility staff was observed with mask on.

Exit interview was conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: OASIS/PALS
FACILITY NUMBER: 107208896
VISIT DATE: 12/20/2021
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Day Program (ADP):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 01/07/2022.

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC809 (FAS) - (06/04)
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