<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206916
Report Date: 09/15/2023
Date Signed: 09/15/2023 12:39:51 PM

Document Has Been Signed on 09/15/2023 12:39 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:VILLAGE GARDENSFACILITY NUMBER:
157206916
ADMINISTRATOR:DIANNA L ELLISFACILITY TYPE:
740
ADDRESS:11910 CROCKETT COURTTELEPHONE:
(661) 587-1191
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 5DATE:
09/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Diana EllisTIME COMPLETED:
12:54 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/15/23, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit. LPA introduced self, stated purpose of visit, and allowed entrance by Administrator, Diana Ellis.

LPA Medina conducted Case Management visit to verify if Staff 1 (S1) is currently working in the facility. Administrator advised an exclusion was ordered and issued by the Department. LPA verified with Administrator that S1 was terminated from facility on September 7, 2023. Administrator disassociated S1 from facility personnel report during case management visit.

No deficiencies sited during this Case Management visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1