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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 12/28/2023
Date Signed: 12/29/2023 08:30:15 PM


Document Has Been Signed on 12/29/2023 08:30 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:
12/28/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Assistant Administrator, Airen MiroTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced POC visit with facility Assistant Administrator Airen Miro to verify correction of citations issued during the visit conducted on 12/01/2023.


Deficiency cited on 12/01/2023, Deficiency Section 87507(g)(3)(C) Any fee that is charged prior to or after admission, shall be clearly specified has not yet been cleared. Licensee has not complied with the terms of the POC by POC due date of 12/15/2023. Civil Penalty for failure correct will be assessed during this visit.


Exit interview conducted with Assistant Administrator, Airen Miro and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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