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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203298
Report Date: 05/22/2024
Date Signed: 05/28/2024 10:31:16 AM

Document Has Been Signed on 05/28/2024 10:31 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:AUTUMN OAKSFACILITY NUMBER:
547203298
ADMINISTRATOR/
DIRECTOR:		ONG, ANTONIO G.FACILITY TYPE:
740
ADDRESS:848 N. JAYE STREETTELEPHONE:
(559) 784-4144
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 44CENSUS: 25DATE:
05/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:19 PM
MET WITH:Lisa OngTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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LPA L. Xiong was at the above facility for a case management visit. A tour of the facility was conducted. Residents 1, 2, 3 & were interviewed during the visit. Visit ended due to licensee having a meeting appointment with Tulare Co. Ombudsman.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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