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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206771
Report Date: 04/11/2023
Date Signed: 04/11/2023 11:31:51 AM

Document Has Been Signed on 04/11/2023 11:31 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SAILS APPLETREEFACILITY NUMBER:
157206771
ADMINISTRATOR:JACQUELINE D. TUCKERFACILITY TYPE:
735
ADDRESS:11611 SAN MINIATO AVETELEPHONE:
(661) 570-3035
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 5CENSUS: 4DATE:
04/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Jacqueline D. TuckerTIME COMPLETED:
11:42 AM
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On 4/10/23, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit. LPA introduced self and allowed entrance by Direct Care Staff. LPA Medina met with Administrator, Jacqueline D. Tucker and stated reason for visit.

LPA Medina conducted a subsequent Case Management visit to verify Staff 1 (S1) is currently not working in the facility. LPA verified with Licensee that S1 has not been worked in facility since approximately July 2020. Administrator was advised an exclusion has been ordered and issued by the Department. Administrator disassociated S1 from facility personnel report provided by LPA Medina during visit.

No deficiencies cited during this Case Management visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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