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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209269
Report Date: 10/25/2022
Date Signed: 10/25/2022 02:54:24 PM

Document Has Been Signed on 10/25/2022 02:54 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:HALEYS HOME CARE LLCFACILITY NUMBER:
547209269
ADMINISTRATOR:ARRIAGA, PATRICIAFACILITY TYPE:
740
ADDRESS:1966 DATE AVETELEPHONE:
(559) 854-0523
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 0DATE:
10/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Patricia ArriagaTIME COMPLETED:
03:05 PM
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On 10/25/22, Licensing Program Analyst (LPA) M. Medina conducted an announced Pre-licensing inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensee Patricia Arriaga. LPA toured the facility with Licensee.

The following items have been completed since last visit on 10/20/22: 1) Facility has a First Aid kit and First Aid Manual 2) Fire exit gate is self-latching and 3) Facility has city of Porterville containers for trash pick up.

LPA found that 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 provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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