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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003068
Report Date: 08/13/2024
Date Signed: 08/13/2024 09:49:29 AM

Document Has Been Signed on 08/13/2024 09:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SAN BRUNO HOMEFACILITY NUMBER:
306003068
ADMINISTRATOR/
DIRECTOR:		HEINRICH S.GONZALESFACILITY TYPE:
735
ADDRESS:6959 SAN BRUNOTELEPHONE:
(714) 828-8756
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 3DATE:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Anna TomillosoTIME VISIT/
INSPECTION COMPLETED:
09:55 AM
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 follow up on an incident report regarding the elopement of Client 1 (C1) sent to the Regional Office August 8, 2024.

During the visit, LPA Haley conducted interviews Client 1 (C1), Staff 2 (S2), collected relevant documents, and went to C1's room and made observations.

As a result of today’s case management visit and the information gathered through observation, client and staff interviews, no deficiencies will be cited at this time.

An exit interview was conducted and a copy of this report was provided to Administrator Anna Tomilloso.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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