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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
107208922
Report Date:
06/23/2021
Date Signed:
06/23/2021 11:37:38 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:
GRACE HOME KARE II
FACILITY NUMBER:
107208922
ADMINISTRATOR:
YANG, YUEPING
FACILITY TYPE:
740
ADDRESS:
3093 EVERGLADE AVE
TELEPHONE:
(559) 856-1268
CITY:
CLOVIS
STATE:
CA
ZIP CODE:
93619
CAPACITY:
6
CENSUS:
6
DATE:
06/23/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:39 AM
MET WITH:
of Teng "Jerry" Zheng
TIME COMPLETED:
11:35 AM
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LPA was at the above facility to deliver and obtained signature for annual inspection on 5/25/21.
SUPERVISOR'S NAME:
Sergiy Pidgirny
TELEPHONE:
(559) 650-7923
LICENSING EVALUATOR NAME:
Les Xiong
TELEPHONE:
(559) 410-1772
LICENSING EVALUATOR SIGNATURE:
DATE:
06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2021
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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