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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208901
Report Date: 03/22/2021
Date Signed: 06/15/2021 10:18:49 AM

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:KAREN'S HOUSEFACILITY NUMBER:
107208901
ADMINISTRATOR:JACOBS, TEMIKA TRINAFACILITY TYPE:
735
ADDRESS:4744 W MENLO AVETELEPHONE:
5592753277
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:4CENSUS: 4DATE:
03/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Temika JacobsTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Katie Brown contacted Licensee/Administrator Temika "Kym" Jacobs at the facility to commence a case management visit via telephone due to COVID-19 and pre-cautionary measures.

LPA explained that the purpose of the call is to follow up and obtain additional information regarding three (3) Unusual Incident Reports (IR) received regarding C1. The first IR was received 3/17/21 and two (2) were received on 3/20/21.



No deficiencies cited
Exit interview conducted with Licensee
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021
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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