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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209059
Report Date: 10/08/2021
Date Signed: 10/08/2021 02:15:42 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:FAMILY STYLE SENIOR ASSISTED LIVINGFACILITY NUMBER:
107209059
ADMINISTRATOR:FERGUSON, JENNIFERFACILITY TYPE:
740
ADDRESS:2202 STANFORD AVETELEPHONE:
(559) 246-0521
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gerald Fickle caregiver and Administrator Jennifer Ferguson via telephoneTIME COMPLETED:
01:45 PM
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On 10/08/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced at facility to conduct an Annual Inspection - Infection Control. LPA met with caregiver Gerald (Jerry) Fickle. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. Caregiver called Administrator Jennifer Ferguson. LPA spoke with Administrator via telephone. Administrator states not able to meet with LPA for the annual inspection and authorized caregiver to sign report. The department will return at a later date to conduct Annual Inspection. A copy of report submitted via email to administrator and an electronic read receipt confirms receiving this email.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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