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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208929
Report Date: 07/31/2023
Date Signed: 07/31/2023 01:14:02 PM


Document Has Been Signed on 07/31/2023 01:14 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:GAITHER'S FAMILY HOME #3FACILITY NUMBER:
547208929
ADMINISTRATOR:GAITHER, HENRIETTAFACILITY TYPE:
740
ADDRESS:1302 E CARMELO AVETELEPHONE:
(559) 687-0300
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:6CENSUS: 6DATE:
07/31/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:House Manager, Nancy ThompsonTIME COMPLETED:
01:19 PM
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On 07/31/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a POC visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. House Manager, Nancy Thompson contacted Administrator via telephone. LPA received verbal permission to meet with the House Manager.

The purpose of today's visit is to clear a deficiency that was issued during the annual inspection.

No deficiencies issued. Exit interview conducted and a copy of this report was discussed and provided to House Manager, Nancy Thompson whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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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