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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203298
Report Date: 06/27/2022
Date Signed: 06/27/2022 01:52:21 PM

Document Has Been Signed on 06/27/2022 01:52 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:AUTUMN OAKSFACILITY NUMBER:
547203298
ADMINISTRATOR:ONG, ANTONIO G.FACILITY TYPE:
740
ADDRESS:848 N. JAYE STREETTELEPHONE:
(559) 784-4144
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 44CENSUS: 24DATE:
06/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Julius DacpanoTIME COMPLETED:
02:12 PM
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On 6/27/2022, Licensing Program Analysts (LPAs) M. Medina and V. Gorban arrived to conduct a Case Management visit related to concerns reported to Department. The concerns were reported to Department during an unrelated Complaint Investigation. LPAs introduced themselves and met with Direct Care Staff. Tony Ong, Administrator contacted by telephone. Administrator was not available for today's Case Management visit.

Facility toured . LPA will conduct follow up inspection, this requires further investigation.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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