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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
414002538
Report Date:
10/03/2019
Date Signed:
10/03/2019 11:44:37 AM
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:
KERSEG, SARAH E.
FACILITY NUMBER:
414002538
ADMINISTRATOR:
KERSEG, SARAH E.
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(650) 341-9716
CITY:
FOSTER CITY
STATE:
CA
ZIP CODE:
94404
CAPACITY:
14
CENSUS:
11
DATE:
10/03/2019
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
11:14 AM
MET WITH:
Sarah Kerseg
TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst Cowan met with licensee Sarah Kerseg to clear Fingerprint deficiency. Present in the facility is licensee and helper Maria Garcia. Licensee presented a copy of the Livescan form for Teresa Garcia. LPA cleared deficiency.
SUPERVISOR'S NAME:
Alma Malig
TELEPHONE:
(650) -26-8800
LICENSING EVALUATOR NAME:
April Cowan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
10/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/03/2019
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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