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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005379
Report Date: 08/29/2019
Date Signed: 08/29/2019 04:00:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ANDREWSCAMPSFACILITY NUMBER:
214005379
ADMINISTRATOR:FRIERSON, ANDREWFACILITY TYPE:
840
ADDRESS:400 TAMAL PLAZA, #401ATELEPHONE:
(415) 446-8946
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:96CENSUS: DATE:
08/29/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Andrew FriersonTIME COMPLETED:
04:20 PM
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Licensing Program Manager (LPM) Leung and Licensing Program Analyst (LPA) Van met with licensee, Andrew Frierson. The purpose of the inspection was to discuss the Stipulation, Waiver and Order dated on May 13, 2019. Present are 42 children and 9 staff members.

LPM reviewed each section of the Stipulation, Waiver and Order with Licensee.
· Licensee must remain in strict compliance with the regulations.
· All adults working in the facility must have criminal record clearances on file with the department.
· Facility shall maintain the Comprehensive Plan for Supervision of Staff and High School Assistant Counselors
· Facility must report to the licensing office any unusual incident including, client death or injury, and any suspected physical or psychological abuse of any client, any physical plant changes and all unexplained absences.
· The department in its sole discretion may conduct unannounced site visits for purpose of determining whether there is full compliance with the regulations.
· The licensee understands that the probationary period is three years

A copy of the Stipulation, Waiver and Order were discussed with the director. A copy of this report was reviewed and provided to the director.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019
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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