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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206554
Report Date: 10/09/2020
Date Signed: 10/23/2020 01:55:03 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
FACILITY NAME:KAZLIN INFINITE CARE LLCFACILITY NUMBER:
247206554
ADMINISTRATOR:MAGLIBA, ESTRELLITOFACILITY TYPE:
740
ADDRESS:3554 EL REDONDO DRIVETELEPHONE:
(209) 349-8457
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:6CENSUS: DATE:
10/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Erlina Magliba, AdministraorTIME COMPLETED:
04:25 PM
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Licensing Program Analyst Lady Cabrera contacted Administrator Erlina Magliba.

The purpose of the case management phone call is to follow-up on the health and safety check of Resident 1 (R1) and to obtain additional information. The incident occurred on 10/04/2020 and it was reported to Community Care Licensing on 10/07/2020.

LPA requested to submit to CCLD the following documents:



1. Recent Physician report
2. Mercy Medical Center Merced discharge papers

The above documents shall be submitted to CCLD by 10/13/2020 (COB)

The original LIC809 will be emailed to Administrator with intent to obtain a signature. The report will be signed and submitted to CCLD by 10/12/2020.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020
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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