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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209171
Report Date: 07/10/2023
Date Signed: 07/10/2023 02:59:59 PM

Document Has Been Signed on 07/10/2023 02:59 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:GURROLA CARE HOME #3FACILITY NUMBER:
547209171
ADMINISTRATOR:GURROLA, MARY ELLENFACILITY TYPE:
740
ADDRESS:287 TEAPOT DOME #BTELEPHONE:
(559) 719-7484
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 4DATE:
07/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Mary Ellen GurrolaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst Katie Brown conducted a Case Management – Health Checks. LPA met with and explained the reason for the visit with Licensee/Administrator (AD) Mary Ellen Gurrola.

The purpose of the visit is to verify the address of the facility. There are two homes on the property of 287 Teapot Dome. During this visit, LPA verified the following with AD:

1. 287 B1 Teapot Dome is the private residence of AD..
2. 287 B2 is the address of the facility.

AD has agreed to update the numbers on the front of both homes.

There were no citations issued during the visit.








An exit interview was conducted and a copy of this report was left with , whose signature confirms receipt of these documents.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2023
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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