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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208235
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:03:15 PM

Document Has Been Signed on 09/18/2024 04:03 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DE BOER HOME #3FACILITY NUMBER:
547208235
ADMINISTRATOR/
DIRECTOR:		DE BOER, BREANNFACILITY TYPE:
735
ADDRESS:2221 W. WHITE CHAPEL WAYTELEPHONE:
(559) 350-3695
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 4DATE:
09/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:14 PM
MET WITH:Walter IdolyantesTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Today, Licensing Program Analyst L. Xiong was at the facility conducting an unannounced Case Management to finalized an annual visit on 9/17/24. LPA met with staff Walter Idolyantes and spoke to House Manager Shawna Treadwell on the phone and inform them the purpose of the visit.

Staff brought personnel and resident records for review.

Fire extinguisher present with a service date of 8/2023. Water temperature observed to measure at 115 degrees F.

No deficiencies were observed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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