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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208764
Report Date: 05/11/2021
Date Signed: 05/11/2021 11:26:01 AM

Document Has Been Signed on 05/11/2021 11:26 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:WILLIAM'S RESIDENTIAL CARE FOR THE ELDERLY LLCFACILITY NUMBER:
107208764
ADMINISTRATOR:RUNDERSON, MARTHA MFACILITY TYPE:
740
ADDRESS:2909 EAST GRIFFITH WAYTELEPHONE:
(559) 226-1082
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY: 3CENSUS: 2DATE:
05/11/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Twioneshia Miles, Staff TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) S. Moua conducted a Health & Safety case management inspection on this date. Inspection was conducted in conjunction with opening a complaint. LPA met with staff Twioneshia Miles. Administrator Martha was called and informed of the inspection.

Facility was toured. Residents were observed. There appears to be sufficient supply of perishable and non-perishable food.

No immediate health or safety concerns were observed.

Exit Interview was conducted.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: See Moua
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2021
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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