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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 09/12/2023
Date Signed: 11/22/2023 02:32:49 PM


Document Has Been Signed on 11/22/2023 02:32 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: 2DATE:
09/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Staff, Octavia McveaTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPA's) Sarah Hurt and Brianna Miranda conducted an unannounced facility visit conduct a Case Management visit. LPA's were greeted by facility staff Octavia Mceva and allowed entry into the facility. LPA's spoke with Licensee Jessica Johnson over the phone and explained the purpose of today's visit.


LPA's requested complete files for Resident 1, and Resident 2 including most recent Physician's Report, Needs and Services Plan, Emergency face sheet, and any incident reports by end of business day on September 15, 2023. LPA's requested Pre - Admission Appraisal, and Physicians Report for Resident 3.


LPA's previously requested current Personnel Report (LIC 500). Licensee has yet to submit. LIC 500 needs to be submitted by end of business day on September 15, 2023.

LPA's delivered notification of Non- Compliance Conference to be held in the Fresno Regional Office (1314 E. Shaw Ave., Fresno CA, 93710) at 10:00 a.m. on September 21, 2023. LPA's informed this meeting is to be held in person and not online.

Non-Compliance Conference letter was left with facility staff Octavia Mcvea.

Licensee Jessica Johnson requested facility staff Octavia Mcvea not sign the report.

No Deficiencies Cited today per Title 22 Regulations

Exit interview conducted with Licensee Jessica Johnson over the phone 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: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
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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