<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202809
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:53:24 PM

Document Has Been Signed on 01/25/2024 04:53 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:TRANSITIONAL LIVING CENTERFACILITY NUMBER:
547202809
ADMINISTRATOR:LEIGH (CABEJE), TAMARAFACILITY TYPE:
735
ADDRESS:546 E. TULARE AVENUETELEPHONE:
(559) 733-6648
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 38CENSUS: 32DATE:
01/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mental Health Program Manager II (MHPM II) Rosie Ruiz (Maduena)TIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An unannounced Case Management - Incident visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. McClurg. LPA met with Mental Health Program Manager II (MHPM II) Rosie Ruiz (Maduena). Admin authorized MHPM II & MHCM III to conduct visit with LPA.

Purpose of visit was to review 1/24/24 Death Report as submitted by the facility regarding Resident 1 (R1).

During this visit, LPA reviewed information as submitted & obtained R1's complete resident file for removal from the facility during this visit.

In accordance with 80070(d)(3) Client Records:
...Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
Licensing representatives shall return the records undamaged and in good order within three business days following the date the records were removed.

Process of removal & return of records for R1 reviewed with MHPM II.
Exit interview conducted with MHPM II. Copy of report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1