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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
107208918
Report Date:
09/27/2021
Date Signed:
09/30/2021 11:16:35 AM
Document Has Been Signed on
09/30/2021 11:16 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:
HARVEST AT FOWLER, THE
FACILITY NUMBER:
107208918
ADMINISTRATOR:
ZANIN, ALEX
FACILITY TYPE:
740
ADDRESS:
1400 E SUMNER AVE
TELEPHONE:
(559) 834-5692
CITY:
FOWLER
STATE:
CA
ZIP CODE:
93625
CAPACITY:
36
CENSUS:
DATE:
09/27/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:35 PM
MET WITH:
Administrator Alex Zanin
TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced Case Management visit to return Resident record file. LPA discussed the purpose of the visit and met with
Administrator Alex Zanin
.
SUPERVISORS NAME
:
Sergiy Pidgirny
LICENSING EVALUATOR NAME
:
Shawna Doucette
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/27/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/27/2021
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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