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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
157206783
Report Date:
05/27/2022
Date Signed:
05/27/2022 02:29:43 PM
Document Has Been Signed on
05/27/2022 02:29 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:
VALLE BONITA HOME
FACILITY NUMBER:
157206783
ADMINISTRATOR:
VILLEGAS, BEATRICE
FACILITY TYPE:
735
ADDRESS:
3912 FAIRMOUNT STREET
TELEPHONE:
(661) 301-0809
CITY:
BAKERSFIELD
STATE:
CA
ZIP CODE:
93306
CAPACITY:
4
CENSUS:
4
DATE:
05/27/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:01 PM
MET WITH:
Henry Villegas
TIME COMPLETED:
02:47 PM
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On this day, LPA was at the above facility to follow up on an incident occurred on 5/23/22. Administrator will email requested documents to CCL by 6/10/22.
SUPERVISORS NAME
:
Sergiy Pidgirny
LICENSING EVALUATOR NAME
:
Les Xiong
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/27/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/27/2022
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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