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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209269
Report Date: 11/21/2022
Date Signed: 12/01/2022 03:52:51 PM

Document Has Been Signed on 12/01/2022 03:52 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:
11/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Patricia ArriagaTIME COMPLETED:
11:53 AM
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LPA, L. Xiong was at the above facility to conduct a case management inspection regarding change of 6 ambulatory status to 6 non-ambulatory status. The facility has been granted the 6 non-ambulatory by fire inspector on November 18th, 2022. A tour of the facility was conducted during the inspection. No deficiency cited and the facility is ready for non-ambulatory placement as of today's date.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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