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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209024
Report Date: 04/07/2021
Date Signed: 04/27/2021 12:13:39 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:DIAL FOR CARE INC.FACILITY NUMBER:
107209024
ADMINISTRATOR:ANGELICA MOJICAFACILITY TYPE:
740
ADDRESS:1472 E. SAMPLE AVETELEPHONE:
(559) 878-3138
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 2DATE:
04/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Amanda Chairez, Designated RepresentativeTIME COMPLETED:
02:30 PM
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On 3/4/2021, Community Care Licensing received the Unusual Incident/Injury Report that occurred on 03/03/2021. The purpose of the phone call is to follow-up on the health and safety check of the client and to obtain additional information. According to the Designated Representative, the client is doing well, has adjusted to her medication and reported no issues at this moment.

LPA requested client's medications list, behavioral plan and Regional Center Case Manager contact information. The listed documents will be submitted to CCLD by 4/9/2021.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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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