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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208243
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:37:03 PM

Document Has Been Signed on 06/22/2023 02:37 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:ENCLAVE AT THE FOOTHILLSFACILITY NUMBER:
547208243
ADMINISTRATOR:HERNANDEZ, JAVIERFACILITY TYPE:
735
ADDRESS:10650 ROAD 256TELEPHONE:
(559) 527-5091
CITY:TERRA BELLASTATE: CAZIP CODE:
93270
CAPACITY: 100CENSUS: 17DATE:
06/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Javier Hernandez
David Shellhamer		TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melinda Medina and Licensing Program Manager (LPM) Melinda Hoffmann conducted an unannounced case management visit. LPA Medina informed Administrator, Javier Hernandez and Director of Residential Services, David Shellhamer the reason for the visit.

On 6/20/23, the Department was made aware that on 6/6/23, the facility was issued a Notice of Violation from Tulare County Resource Management in relation to violation of Section 9.55 of the Tulare County Ordinance Code 352 governing AE10. Facility did not report this to licensing.

Deficiency cited in the attached per Title 22, Section 80061. Appeal rights provided to Administrator.

Deficiencies cited on the attached 809D.

Exit interview conducted and a copy of report was provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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Document Has Been Signed on 06/22/2023 02:37 PM - It Cannot Be Edited


Created By: Melinda Medina On 06/22/2023 at 01:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ENCLAVE AT THE FOOTHILLS
FACILITY NUMBER: 547208243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
80061(b)

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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal
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By the due date, facility shall submit an incident report, detailing the violation received and their plan to adhere to it. Plan shall include the steps that will be taken to ensure that incidents are reported as required.
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business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
This requirement was not met when facility did not report the notice of violation they received on 6/6/23 to licensing.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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