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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202420
Report Date: 12/15/2023
Date Signed: 12/15/2023 10:44:39 AM


Document Has Been Signed on 12/15/2023 10:44 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:COTTAGE LLC, THEFACILITY NUMBER:
547202420
ADMINISTRATOR:SIEGEL, DELENAFACILITY TYPE:
740
ADDRESS:19127 AVENUE 150TELEPHONE:
(559) 781-5777
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 6DATE:
12/15/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Howard Ferguson
Terry Overstreet via Telephone		TIME COMPLETED:
11:00 AM
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On 12/15/23, this Department conducted a office meeting to discuss control of property for facility. Present during meeting were Brenda White, Regional Manager, Melinda Hoffmann, Licensing Program Manager, Melinda Medina, Licensing Program Analyst, Howard Ferguson, and Terry Overstreet via telephone.

The Department has requested the following documents be submitted no later than 12/20/23: LIC 200, LIC 308, LIC 309, Lease Agreement, Appointment Letter for Administrator to be completed by Licensee, Terry Overstreet.

This report will be emailed as Licensee was in attendance via telephone.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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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