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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209054
Report Date: 02/15/2024
Date Signed: 02/15/2024 09:36:02 AM

Document Has Been Signed on 02/15/2024 09:36 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:WILLY HOMEFACILITY NUMBER:
157209054
ADMINISTRATOR:AGUSTO, STACYRAEFACILITY TYPE:
734
ADDRESS:3702 ABBEY ROADTELEPHONE:
(661) 843-7739
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 4DATE:
02/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Registered Nurse, John YoroTIME COMPLETED:
09:40 AM
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Licensing Program Analyst (LPA) Darius Williams conducted a case management visit in response to a Decision and Order issued by the Department in regards to Staff 1. LPA Williams met with Registered Nurse, John Yoro and spoke with the Administrator Stacyrae Agusto via phone.

Administrator reported Staff 1 is not employed at the facility and will remove the individual from Guardian. Administrator also reported filling out paperwork and returning it to the Department verifying that Staff 1 is not employed at the facility.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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