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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
107206861
Report Date:
11/10/2021
Date Signed:
11/10/2021 02:28:19 PM
Document Has Been Signed on
11/10/2021 02:28 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 VILLA
FACILITY NUMBER:
107206861
ADMINISTRATOR:
HRIPSIME MAKARYAN
FACILITY TYPE:
740
ADDRESS:
2020 NORTH WEBER AVENUE
TELEPHONE:
(559) 486-5977
CITY:
FRESNO
STATE:
CA
ZIP CODE:
93705
CAPACITY:
100
CENSUS:
DATE:
11/10/2021
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
02:14 PM
MET WITH:
Hripsime (Kristina) Makaryan
TIME COMPLETED:
03:00 PM
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On this date, LPA was at the above facility to follow up on an incident that occurred on 10/24/21 regarding R1.
SUPERVISORS NAME
:
Sergiy Pidgirny
LICENSING EVALUATOR NAME
:
Les Xiong
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/10/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/10/2021
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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