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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209295
Report Date: 07/10/2023
Date Signed: 08/03/2023 09:14:42 AM

Document Has Been Signed on 08/03/2023 09:14 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PROVIDENT HEALTH CARE TAMARACKFACILITY NUMBER:
247209295
ADMINISTRATOR:TIU, JERRYFACILITY TYPE:
735
ADDRESS:1390 5TH STREETTELEPHONE:
(209) 388-1002
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 5CENSUS: 2DATE:
07/10/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Maria SimonTIME COMPLETED:
03:23 PM
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LPA Sarah Hurt met with Facility Administrator Maria Simon to conduct a post licensing inspection. LPA Hurt toured facility bedrooms, bathrooms, living room, kitchen, backyard and dining area. LPA Hurt viewed areas for food storage, medication storage and toxin storage. LPA Hurt observed facility license posted, emergency plan posted, menu posted. First aid kit has adequate supplies. LPA Hurt reviewed resident files for two facility clients. LPA Hurt observed Social Workers and Central Valley Regional Center staff present for meetings with clients and staff.


No deficiencies noted during the post visit.

Exit interview conducted with facility Christina Cisneros and a copy of this report provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2023
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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