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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209321
Report Date: 07/20/2023
Date Signed: 07/20/2023 11:50:13 AM

Document Has Been Signed on 07/20/2023 11:50 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:EBONY HOME LLCFACILITY NUMBER:
547209321
ADMINISTRATOR:THOMPSON, JENNIFERFACILITY TYPE:
735
ADDRESS:669 WEST KANAI AVETELEPHONE:
(559) 310-0271
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 0DATE:
07/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Jennifer ThompsonTIME COMPLETED:
12:21 PM
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
A Prelicensing visit was conducted on the date & during the times indicated above by Licensing Program Analyst (LPA) L. Xiong. LPA met with Administrator, Jennifer Thompson. Physical plant toured. This facility has no pool, spa, hot tub, fountains, etc.
Activity, community, & dining rooms sufficiently furnished with adequate lighting. Kitchen toured. Two (2) day supply of perishable & 7 day supply of non-perishable food on the premises. Resident rooms toured. Rooms sufficiently furnished with adequate lighting. Resident bathrooms toured. Hot water measured at 106 degrees. Interior & exterior passageway observed to be free of obstructions. Facility has a locked medication room. Outside area toured. No deficiency observed.

No outstanding issues. Component III conducted during this visit.
Exit interview conducted with Administrator.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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