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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
107209539
Report Date:
12/11/2024
Date Signed:
12/11/2024 11:32:51 AM
Document Has Been Signed on
12/11/2024 11:32 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
FRESNO RO
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
FRESNO GUEST HOME #25
FACILITY NUMBER:
107209539
ADMINISTRATOR/
DIRECTOR:
LONG, TERESA
FACILITY TYPE:
740
ADDRESS:
2848 E PALO ALTO AVE
TELEPHONE:
(559) 434-1839
CITY:
FRESNO
STATE:
CA
ZIP CODE:
93710
CAPACITY:
6
CENSUS:
0
DATE:
12/11/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:27 AM
MET WITH:
Teresa Long
TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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LPA failed to have Administrator sign document prior to closing the form.
This is to document signature.
SUPERVISORS NAME
:
Sergiy Pidgirny
LICENSING EVALUATOR NAME
:
Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/11/2024
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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