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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203139
Report Date: 09/29/2021
Date Signed: 09/29/2021 06:01:14 PM

Document Has Been Signed on 09/29/2021 06:01 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:KERN TRANSITION HOME-MEADOW OAKSFACILITY NUMBER:
157203139
ADMINISTRATOR:GONZALEZ, TIFFANYFACILITY TYPE:
735
ADDRESS:5813 MEADOW OAKS COURTTELEPHONE:
(661) 871-7410
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY: 4CENSUS: DATE:
09/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:56 PM
MET WITH:TIME COMPLETED:
06:02 PM
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LPA, L. Xiong was at the above facility as a follow up on an incident occurred on 9/20/21 involving R1 and R2. The facility submitted and incident report on 9/20/21 and soc 341 as well. Facility records for R1 and R2 were obtained for review.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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