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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157207101
Report Date: 08/31/2022
Date Signed: 08/31/2022 04:22:18 PM


Document Has Been Signed on 08/31/2022 04:22 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:ALTAVILLE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
157207101
ADMINISTRATOR:NOBLEZA, JOHN & BASILISAFACILITY TYPE:
735
ADDRESS:2603 MOUNT VERNON AVENUETELEPHONE:
(661) 871-3980
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:48CENSUS: DATE:
08/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:Basilisa NoblezaTIME COMPLETED:
05:08 PM
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LPA, L. Xiong came today to the facility for complaint #24-AS-20211201134652. The following are to be completed and provide documentation to Community Care Licensing by 9/15/22.

1. The facility refund $680.87 net unrecorded distributions to the resident's family via resident's payee, Steward, Inc.
2. The facility to request the payee to release the fund to the resident's family.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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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