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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503907281
Report Date: 10/17/2023
Date Signed: 11/20/2023 03:12:02 PM

Document Has Been Signed on 11/20/2023 03:12 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:FLETCHER, DONNA FAMILY CHILD CAREFACILITY NUMBER:
503907281
ADMINISTRATOR:FLETCHER, DONNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 578-5531
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
10/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
11:00 AM
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On 10/17/2023 Licensing Program Analyst (LPA) Anita Tristan attempted an unannounced Case Management visit to obtain LIC 9211- Request for Inactive Status form from Licensee, Donna Fletcher. Licensee was not home; LPA left LIC 9211 at the door. LPA place call to Licensee, who was at a doctor appointment informing Licensee of the form. Licensee stated that she will sign it when she gets home and have LPA return to pick up form.

Licensee did not have any children in care.
SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Anita Tristan
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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