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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208831
Report Date: 09/05/2024
Date Signed: 10/01/2024 09:02:33 AM


Document Has Been Signed on 10/01/2024 09:02 AM - 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:GAITHER'S FAMILY HOMEFACILITY NUMBER:
547208831
ADMINISTRATOR:GAITHER, HENRIETTAFACILITY TYPE:
740
ADDRESS:1441 SAN LUCIA AVENUETELEPHONE:
(559) 920-3939
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:4CENSUS: 4DATE:
09/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Melissa KayTIME COMPLETED:
01:11 PM
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Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct a Case Management visit pertaining to CDSS case no. 7923277004. LPA met staff Melissa Kay and spoke to Asst. Administrator Kristie Rackley on the phone and inform them the purpose of the visit.

Staff M. Kay provided the facility tour for LPA. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Resident bedrooms toured, rooms observed to have all required accommodations. S1 was not present at the facility.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -34-3274
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: 559-410-1772
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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