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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 09/01/2022
Date Signed: 09/01/2022 10:22:04 AM


Document Has Been Signed on 09/01/2022 10:22 AM - It Cannot Be Edited

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: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: 4DATE:
09/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Caregiver, Norma CejaTIME COMPLETED:
10:30 AM
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On 09/01/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. Administrator, Jessica Johnson, is not available to attend this visit. Administrator was contacted via telephone. LPA received verbal permission to meet with Caregiver, Norma Ceja.

The purpose of today's visit is to follow up on an incident reported to the Fresno CCL office and return the complete file for R1 that was removed from the facility on 08/31/2022.

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report was discussed and provided to Caregiver, Norma Ceja, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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