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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206651
Report Date: 01/08/2024
Date Signed: 01/19/2024 04:34:06 PM

Document Has Been Signed on 01/19/2024 04:34 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:EWING PALM HOME, LLCFACILITY NUMBER:
547206651
ADMINISTRATOR:JOHNSON, TIFFANYFACILITY TYPE:
735
ADDRESS:4836 W. JAMES CTTELEPHONE:
(559) 429-4856
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: DATE:
01/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
10:11 AM
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On 1/08/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA rang the doorbell multiple times and knocked on the door with no response. LPA contacted the number on profile and left a message requesting a call back.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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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