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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004649
Report Date: 01/23/2020
Date Signed: 01/23/2020 10:03:54 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:TRAN, LINHFACILITY NUMBER:
414004649
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
01/23/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant, Linh TranTIME COMPLETED:
10:15 AM
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Licensing Program Analysts (LPAs) Kassandra Medrano and Brendon Van met with applicant Linh Tran, the purpose of the visit was discussed. Present today was Applicant and adult daughter. LPAs inspected the entire home and the backyard. During previous inspection conducted on January 02, 2020, applicant was not officially moved into home. LPA informed applicant that she needed to be living in home for licensure. Based on observations today, applicant has now moved into home.

Due to complications with prior license at this address, an office visit will be required by applicant.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2020
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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