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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202486
Report Date: 02/09/2023
Date Signed: 02/09/2023 01:31:54 PM

Document Has Been Signed on 02/09/2023 01:31 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:JEFFRIES HOME 2FACILITY NUMBER:
547202486
ADMINISTRATOR:JEFFRIES, JENNIFERFACILITY TYPE:
735
ADDRESS:1220 LOTAS WAYTELEPHONE:
(559) 783-8639
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
02/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Cija ReedTIME COMPLETED:
01:47 PM
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LPA, L. Xiong was at the above facility to conduct a case management visit as a follow up on exemptional denial for an applicant/staff (S1). I met with staff Cija Reed and spoke to Administrator/Licensee, Jennifer Jeffries and informed them about the purpose of the visit. Jennifer J. is currently out of town and she authorized Cija R. to sign the documents on her behalf.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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