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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209334
Report Date: 09/19/2023
Date Signed: 09/20/2023 08:48:19 AM

Document Has Been Signed on 09/20/2023 08:48 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:CENTRAL VALLEY STAR #2FACILITY NUMBER:
547209334
ADMINISTRATOR:HOOVER, JOSHUAFACILITY TYPE:
738
ADDRESS:32029 SUCCESS VALLEY DRIVETELEPHONE:
(916) 639-4736
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 5CENSUS: 0DATE:
09/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Joshua Hoover and Angie SmithTIME COMPLETED:
12:42 PM
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A Prelicensing visit was conducted on the date & during the times indicated above by Licensing Program Analyst (LPA) L. Xiong. LPA met with Administrator, Joshua Hoover and Program Director, Angie Smith.
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. Bathroom areas toured. Non-skid mats in observed in showers. Hot water measured at 110 degrees. Interior & exterior passageway observed to be free of obstructions. Facility has a locked medication room, locked cabinets for sharps and cleaning supplies. Outside area toured. No hazards observed.

Component III conducted during this visit.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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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