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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208929
Report Date: 07/14/2023
Date Signed: 07/14/2023 02:11:51 PM

Document Has Been Signed on 07/14/2023 02:11 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:GAITHER'S FAMILY HOME #3FACILITY NUMBER:
547208929
ADMINISTRATOR:GAITHER, HENRIETTAFACILITY TYPE:
740
ADDRESS:1302 E CARMELO AVETELEPHONE:
(559) 687-0300
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 6CENSUS: 6DATE:
07/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Qualified Intellectual Disability Professional, Anna McDonald and Facility Staff, Norma EspinozaTIME COMPLETED:
03:04 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 07/14/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual continuation inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Qualified Intellectual Disability Professional, Anna McDonald and Facility Staff, Norma Espinoza.

During today's inspection, LPA reviewed staff files.

No deficiencies issued. LPA received verbal permission to complete the inspection with, Facility Staff, Norma Espinoza. Exit interview conducted. A copy of this report was discussed and provided to Facility Staff, Norma Espinoza, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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 5