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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208995
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:12:12 PM


Document Has Been Signed on 08/20/2024 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:CARMEL VILLAGE AT CLOVISFACILITY NUMBER:
107208995
ADMINISTRATOR:POPE, LINDAFACILITY TYPE:
740
ADDRESS:1650 SHAW AVENUETELEPHONE:
(559) 297-4900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:127CENSUS: DATE:
08/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:Administrator Linda PopeTIME COMPLETED:
03:30 PM
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On 8/20/24 Licensing Program Analysts J. Leffall and K. Kaur arrived unannounced for a case management visit regarding a Default Decision and Order for Staff 1 (S1) Dequisha Smith. LPA's met with Administrator Linda Pope. Linda Pope verified Dequisha Smith is not employed, was never hired and never stepped foot on the premises for employment. LPA's conducted visit to verify the individual previously mentioned is not working at the facility.

LPA's were informed by Administrator that member is not employed at the facility and will be disassociated with the facility.

Exit interview was conducted. A copy of this report was provided to Administrator, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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