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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206861
Report Date: 09/02/2021
Date Signed: 09/02/2021 12:01:37 PM

Document Has Been Signed on 09/02/2021 12:01 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:BELMAR VILLAFACILITY NUMBER:
107206861
ADMINISTRATOR:HRIPSIME MAKARYANFACILITY TYPE:
740
ADDRESS:2020 NORTH WEBER AVENUETELEPHONE:
(559) 486-5977
CITY:FRESNOSTATE: CAZIP CODE:
93705
CAPACITY: 100CENSUS: DATE:
09/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Hripsime "Kristina" MakaryanTIME COMPLETED:
11:24 AM
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Today, LPA, L. Xiong conducted a televisit case management to the above facility. During the televisit, I met with administrator, H. Makaryan and informed her the purpose of the call. The administrator informed LPA that R1 awoled from the facility yesterday (September 1, 2021) morning and returned to the facility last night. She informed LPA that an Unusual Incident Report was generated and faxed to Licensing earlier this morning.

The following documents for R1 was requested by LPA to be sent to Licensing by September 8, 2021:

1. Admission Agreement
2. Physician's Report
3. Emergency Identification contact sheet
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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