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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209297
Report Date: 02/22/2024
Date Signed: 02/22/2024 12:42:05 PM


Document Has Been Signed on 02/22/2024 12:42 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/22/2024 12:32 PM

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

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On 02/22/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conducted a health and safety check. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Nicole Morehead.

LPA conducted a tour of the facility. All passage ways were clear from obstructions. LPA observed an adequate food supply. Residents observed to be watching TV and socializing.

LPA obtained a copy of the residents roster and 602s for all residents in care. LPA is requesting the following documents be submitted to the Fresno CCL office by 02/23/2024: Hospice records, and documentation for ALW residents.

No deficiencies issued.

Exit interview conducted. A copy of this report was discussed and provided Administrator, Nicole Morehead, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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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