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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206249
Report Date: 02/10/2023
Date Signed: 02/12/2023 08:46:53 PM

Document Has Been Signed on 02/12/2023 08:46 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DUTCHOLLOW SUITES III-BOBBIE'S HAVEN OF RESTFACILITY NUMBER:
247206249
ADMINISTRATOR:CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:3739 NOTRE DAME AVENUETELEPHONE:
(209) 384-9368
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY: 6CENSUS: 2DATE:
02/10/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Cecilia CandidoTIME COMPLETED:
12:00 PM
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On 02/10/2023 Licensing Program Analyst (LPA) V Gorban visited announced facility stated above to amend previous report due to inconsistency in verbiage for unsubstantiated findings. LPA met with Licensee and presented the amended report. Report was read by Licensee. Original report was returned back to LPA.

Exit interview was conducted with Licensee Cecilia Candido and report was printed for facility records
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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