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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209306
Report Date: 04/19/2023
Date Signed: 04/19/2023 10:38:29 AM


Document Has Been Signed on 04/19/2023 10:38 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:PSALMS 23 LOVING CARE RESIDENTIAL IIIIFACILITY NUMBER:
107209306
ADMINISTRATOR:COOLEY, I'ISHAFACILITY TYPE:
735
ADDRESS:2210 S EUNICE AVETELEPHONE:
(559) 270-3822
CITY:FRESNOSTATE: CAZIP CODE:
93706
CAPACITY:4CENSUS: DATE:
04/19/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:TIME COMPLETED:
10:35 AM
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Component II completion: Successful

Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: I'Isha Cooley
Interview Method: Telephone interview

On 3/9/23, applicant(s)/administrator participated in COMP II for the below pending facilities: Psalms 23 Loving Care III, 107209303; Psmals 23 Loving Care Residential IIII, 107209306 Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Shannon BetkerTELEPHONE: (916) 651-3018
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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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