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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247204141
Report Date: 04/06/2022
Date Signed: 04/06/2022 10:03:36 AM

Document Has Been Signed on 04/06/2022 10:03 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:C AND D'S GUEST HOME #6FACILITY NUMBER:
247204141
ADMINISTRATOR:DOBBINS, CHANTEFACILITY TYPE:
735
ADDRESS:6314 ATWATER JORDAN RDTELEPHONE:
(209) 357-5195
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 6CENSUS: DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Lacey JacksonTIME COMPLETED:
10:06 AM
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On 04/06/2022, Licensing Program Analyst (LPA) Walton arrived unannounced and attempted to conduct an Annual Inspection. LPA knocked on the facility door and did not receive a response. There are no staff or residents present at the facility during this time. LPA placed a telephone call to Administrator, Lacey Jackson and left a voicemail. LPA left a business card with LPA's contact information on the door of the facility.

LPA will return on a later date to conduct the Annual Inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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