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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 03/23/2022
Date Signed: 03/23/2022 11:59:07 AM

Document Has Been Signed on 03/23/2022 11:59 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:ATWATER RESIDENTIAL CARE FACILITYFACILITY NUMBER:
247209209
ADMINISTRATOR:JOHNSON, JESSICAFACILITY TYPE:
740
ADDRESS:1691 JOE SILVA AVENUETELEPHONE:
(209) 430-1688
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 4CENSUS: 0DATE:
03/23/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Licensee, Jessica Johnson and Administrator, Amish MunshiTIME COMPLETED:
12:03 PM
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On 03/23/2022, Licensing Program Analyst (LPA) A. Walton conducted an announced Case Management Inspection. LPA Walton introduced self, stated purpose of visit, and was allowed entry into the facility. LPA met with:

Licensee: Jessica Johnson

Administrator: Amish Munshi

The purpose of this visit is to follow up on the corrected items identified during the Pre-Licensing Inspection dated 03/16/2022. LPA conducted a tour with Licensee and Administrator. The smoke detector has been attached to the ceiling in bedroom 3 and carpet has been secured in bedroom 3. Grab bars have been installed by the bathroom toilets. Additional linens was observed in the hallway closet. Hot water measured between 109.2 - 116.0 degrees F. Fire extinguisher was last serviced on 03/21/2022.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

Exit interview conducted. A copy of this report was discussed and provided to Licensee, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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