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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206577
Report Date: 02/02/2024
Date Signed: 02/02/2024 01:33:08 PM


Document Has Been Signed on 02/02/2024 01:33 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:DOMINGO HOME, THEFACILITY NUMBER:
547206577
ADMINISTRATOR:DOMINGO, WALTER OR FEFACILITY TYPE:
740
ADDRESS:2069 LINDA VISTATELEPHONE:
(559) 784-2762
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 3DATE:
02/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Fe DomingoTIME COMPLETED:
02:04 PM
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On or about the above date, LPA Les Xiong was at the above facility conducting a case management visit for the purpose of health and safety check. LPA met with Licensee/Administrator Fe Domingo during the visit. LPA spoke to licensee regarding the purpose of the visit. LPA toured the facility and reviewed facility records relevant to the visit. No hazard observed during the visit.

No deficiencies cited for the visit.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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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