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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206907
Report Date: 12/03/2021
Date Signed: 12/03/2021 03:29:13 PM

Document Has Been Signed on 12/03/2021 03:29 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:UNION VILLAFACILITY NUMBER:
157206907
ADMINISTRATOR:MONTIANO, NANCYFACILITY TYPE:
735
ADDRESS:1102 S. UNION AVE.TELEPHONE:
(661) 323-0768
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 89CENSUS: 60DATE:
12/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Staff Dennis MontianoTIME COMPLETED:
01:00 PM
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Licensing Program Analysts LPA(s) K.Kaur and S. Doucette conducted a Case Management to follow up on incident that occurred on 11/12/2021. LPA(s) was met by Staff Yvonne Agassid who followed COVID 19 precautions. LPA(s) contacted Administrator Nancy Montiano via phone who gave permission for staff Dennis Montiano to sign for this report. LPA(s) discussed the purpose of the visit.

LPAs interviewed staff regarding this incident. Facility followed proper procedures. No deficiencies cited

An exit interview was conducted with staff Dennis Montiano. As a COVID-19 precautionary measure, a copy of this signed report will be provided via email.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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