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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 10/10/2023
Date Signed: 10/24/2023 10:40:31 PM


Document Has Been Signed on 10/24/2023 10:40 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:ATWATER RESIDENTIAL CARE FACILITYFACILITY NUMBER:
247209209
ADMINISTRATOR:JOHNSON, JESSICAFACILITY TYPE:
740
ADDRESS:1691 JOE SILVA AVENUETELEPHONE:
(209) 430-1688
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:5CENSUS: 3DATE:
10/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Licensee Jessica JohnsonTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Sarah Hurt and Vadim Gorban conducted an unannounced Case Management visit. LPA’s met with facility Licensee Jessica Johnson and explained the purpose of today’s visit.

LPA's walked around and toured the facility resident bedrooms, backyard area, kitchen, and common areas.

LPA Hurt provided Licensee with Licensing form 311F

LPA Hurt provided Licensee with Community Care Licensing / Medications Guide


No Deficiencies Cited today Per Title 22 Regulations.

Exit interview conducted with Licensee Jessica Johnson, and a copy of this report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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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