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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208930
Report Date: 07/05/2022
Date Signed: 07/05/2022 11:39:15 AM


Document Has Been Signed on 07/05/2022 11:39 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:WINDHAM, THEFACILITY NUMBER:
107208930
ADMINISTRATOR:METZ, KELLYFACILITY TYPE:
740
ADDRESS:1100 E SPRUCE AVETELEPHONE:
(559) 449-8070
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:88CENSUS: 73DATE:
07/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator, John EarleyTIME COMPLETED:
11:51 AM
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On 07/05/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit at the above facility. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, John Earley.

The purpose of today visit is to follow up on an incident report submitted to the Fresno CCL office on 06/16/2022. LPA reviewed resident and staff records.

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, John Earley, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
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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