<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208928
Report Date: 10/06/2023
Date Signed: 10/06/2023 11:18:15 AM

Document Has Been Signed on 10/06/2023 11:18 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GAITHERS FAMILY HOME #2FACILITY NUMBER:
547208928
ADMINISTRATOR:MCDONALD, ANNAFACILITY TYPE:
735
ADDRESS:590 W MCCOMB AVETELEPHONE:
(559) 686-2663
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 5DATE:
10/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Wendy MacielTIME COMPLETED:
11:46 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPAs L. Xiong and L. Padgett were at the above facility conducting a case management inspection as a follow-up on an incident Community Care Licensing(CCL) received on 9/28/23. L. Xiong called and spoke to Administrator Anna McDonald on the phone and informed her the purpose of the visit, and the incident. During the inspection, it was discovered resident #1(R1) lived in a SLS home at 177 S. H Street, which is not within CCL's jurisdiction. R1 does not live at the above facility.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1