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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206782
Report Date: 12/08/2022
Date Signed: 12/14/2022 02:16:13 PM

Document Has Been Signed on 12/14/2022 02:16 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:EMPLOY AMERICAFACILITY NUMBER:
547206782
ADMINISTRATOR:SUZANNE COPELANDFACILITY TYPE:
775
ADDRESS:340 N. FOURTH STTELEPHONE:
(559) 443-7119
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 90CENSUS: 33DATE:
12/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Danielle BeltranTIME COMPLETED:
02:28 PM
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LPA, L. Xiong, was at the above facility for a case management visit. I met with Danielle Beltran, Program Director and discuss with her the incident related to C1 and S1. The facility will fax all documents related to the incident to licensing by December 15, 2022.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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