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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209250
Report Date: 09/27/2022
Date Signed: 09/27/2022 04:07:06 PM

Document Has Been Signed on 09/27/2022 04:07 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MERZOIAN RANCH 2 LLCFACILITY NUMBER:
547209250
ADMINISTRATOR:EVANS, KIMILAFACILITY TYPE:
740
ADDRESS:668 W. WILLOW OAK AVE.TELEPHONE:
(559) 361-5356
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: DATE:
09/27/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Dwayne Story-LLC Managing Member; Kimila Evans-AdministratorTIME COMPLETED:
03:33 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 4
COMP II Participants: Dwayne Story, LLC Managing Member; Kimila Evans, Administrator
Interview Method: Telephone interview

On 9/27/22, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements/CPMB associations & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Anna Barrios
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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