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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 540408972
Report Date: 11/06/2023
Date Signed: 11/06/2023 10:43:25 AM

Document Has Been Signed on 11/06/2023 10:43 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:PORTERVILLE SHELTERED WORKSHOPFACILITY NUMBER:
540408972
ADMINISTRATOR:MARSHA SHOEMAKEFACILITY TYPE:
775
ADDRESS:621 SOUTH E STREETTELEPHONE:
(559) 784-1399
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 270CENSUS: DATE:
11/06/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Marsha ShoemakeTIME COMPLETED:
11:14 AM
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LPA was at the above for a collateral visit. I met with Program Supervisor III Marsha Shoemake and informed her the purpose of the visit.

I met spoke with a Client (R1) during the visit in regards to complaint #24-AS-20230824090157.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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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