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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208828
Report Date: 05/03/2023
Date Signed: 05/03/2023 01:27:59 PM

Document Has Been Signed on 05/03/2023 01:27 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:A GOLDEN HEART FAMILY CAREFACILITY NUMBER:
157208828
ADMINISTRATOR:LIGON, MICHELLEFACILITY TYPE:
740
ADDRESS:13402 GIRO DRIVETELEPHONE:
(661) 368-2333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 6DATE:
05/03/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Administrator, Michelle Ligon and Administrator Jocelyn LigonTIME COMPLETED:
01:43 PM
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On 05/03/2023, Licensing Program Analyst (LPA) A. Walton arrived at the facility unannounced to conduct a Case Management - Annual Continuation. LPA introduced self, stated the purpose of the visit and was allowed to enter the facility. LPA met with Administrator, Michelle Ligon and Administrator Jocelyn Ligon.

LPA reviewed facility staff and resident records.

LPA is requesting the following documents be submitted to the Fresno CCL office by 06/03/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), Surety Bond

No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Michelle, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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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