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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
107208986
Report Date:
08/22/2022
Date Signed:
08/22/2022 02:21:43 PM
Document Has Been Signed on
08/22/2022 02:21 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:
FRESNO GUEST HOME XII
FACILITY NUMBER:
107208986
ADMINISTRATOR:
KUTNERIAN, GEORGE
FACILITY TYPE:
740
ADDRESS:
2398 E. LOS ALTOS AVENUE
TELEPHONE:
(559) 434-1839
CITY:
FRESNO
STATE:
CA
ZIP CODE:
93710
CAPACITY:
6
CENSUS:
6
DATE:
08/22/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:24 PM
MET WITH:
Angela Kutnerian, Licensee Representative
TIME COMPLETED:
01:36 PM
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Licensing Program Analyst (LPA) L. Cabrera was unable to conduct Annual Inspection at this time due to License Anniversary date.
SUPERVISORS NAME
:
Sergiy Pidgirny
LICENSING EVALUATOR NAME
:
Lady Cabrera
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/22/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/22/2022
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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