<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003068
Report Date: 06/23/2022
Date Signed: 06/23/2022 02:49:42 PM

Document Has Been Signed on 06/23/2022 02:49 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SAN BRUNO HOMEFACILITY NUMBER:
306003068
ADMINISTRATOR:HEINRICH S.GONZALESFACILITY TYPE:
735
ADDRESS:6959 SAN BRUNOTELEPHONE:
(714) 828-8756
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 3DATE:
06/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Annamarie TomillosoTIME COMPLETED:
02:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to San Bruno Home. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called Staff 1 (S1) who arrived and was present for the visit.

The purpose today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC624) that was sent to the Orange County Adult and Senior Care Regional Office June 1, 2022.

On today's visit LPA Haley conducted an interview with S1 regarding the incident involving Staff 2 (S2) and what has happened since the reported incident.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted with S1 and a copy of this report was provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1