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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202420
Report Date: 12/20/2023
Date Signed: 12/20/2023 09:41:49 AM

Document Has Been Signed on 12/20/2023 09:41 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:COTTAGE LLC, THEFACILITY NUMBER:
547202420
ADMINISTRATOR:SIEGEL, DELENAFACILITY TYPE:
740
ADDRESS:19127 AVENUE 150TELEPHONE:
(559) 781-5777
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
12/20/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Howard FergusonTIME COMPLETED:
09:46 AM
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On 12/20/23, this Department conducted a office meeting to follow up on previous meeting held on 12/15/23. Present during meeting were Brenda White, Regional Manager, Melinda Medina, Licensing Program Analyst, and Howard Ferguson.

The Department has received the following documents provided by Howard Ferguson during office visit: LIC 200, LIC 308, LIC 309, Lease Agreement, Appointment Letter for Administrator, Certificate of Liability Insurance, and Articles of Incorporation with Statement of Conversion.

This Department will review documents received and will advise if any additional information is needed.

A copy of this report was provided to Howard Ferguson during meeting.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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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