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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406456
Report Date: 09/29/2023
Date Signed: 09/29/2023 03:20:29 PM

Document Has Been Signed on 09/29/2023 03:20 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CENTRE VILLAGEFACILITY NUMBER:
150406456
ADMINISTRATOR:GRIGSBY, DIEDRAFACILITY TYPE:
735
ADDRESS:2500 GOSFORD ROADTELEPHONE:
(661) 836-2500
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 76CENSUS: 56DATE:
09/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Administrator, Nora RodriguezTIME COMPLETED:
12:27 PM
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Licensing Program Analyst (LPA) Darius Williams conducted a facility visit in regards to a State Decision and Order. LPA Williams met with the Administrator and discussed the purpose of the visit.

Administrator reported Staff 1 is not on any of the facility schedules.

Per conversation with Human Resource Manager on 9/20/2023, it was confirmed that S1 was no longer employed since June 2023.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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