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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208995
Report Date: 07/31/2020
Date Signed: 07/31/2020 01:47:29 PM

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:CARMEL VILLAGE AT CLOVISFACILITY NUMBER:
107208995
ADMINISTRATOR:SCHUK, ERIKFACILITY TYPE:
740
ADDRESS:1650 SHAW AVENUETELEPHONE:
(559) 297-4900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:127CENSUS: DATE:
07/31/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Pauline BarkerTIME COMPLETED:
02:30 PM
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On this date, LPA D. Wright spoke with acting Administrator Pauline Barker via telephone for precautionary measures due to COVID-19. The purpose was to verify that an employee that was not granted a criminal record exemption is not working at the facility. Pauline verified that the individual did not work at the facility. LPA emailed Pauline the confirmation of removal form, and requested she sign it, and return it to LPA via email. An electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (559) 650-7908
LICENSING EVALUATOR NAME: Dixie Marie WrightTELEPHONE: (559) 772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020
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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