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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 240403819
Report Date: 12/02/2021
Date Signed: 12/02/2021 02:15:51 PM

Document Has Been Signed on 12/02/2021 02:15 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:KINGS VIEW WORK EXPERIENCE CENTERFACILITY NUMBER:
240403819
ADMINISTRATOR:KALEMBER, SAMUELFACILITY TYPE:
775
ADDRESS:100 AIRPARK ROADTELEPHONE:
(209) 357-0321
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 200CENSUS: 0DATE:
12/02/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Program Director, Gila OchoaTIME COMPLETED:
11:02 AM
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On 12/2/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct a Case Management-Annual Continuation inspection. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Program Director (PD), Gila Ochoa. LPA observed a temperature check/visitor log.

During today's inspection LPA conducted a facility tour and reviewed client and staff records.

Resident records were observed to have updated emergency contact information. Facility staff records were reviewed for good health and infection control training.

No deficiencies observed.

An exit interview was conducted with PD. As a COVID-19 precautionary measure, a copy of this report will be provided to PD via email and an electronic read receipt confirms receiving this document. Report signed on-site by Facility Representative.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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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