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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
385600003
Report Date:
04/28/2022
Date Signed:
08/01/2023 11:46:47 AM
Document Has Been Signed on
08/01/2023 11:46 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
CCLD Regional Office
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
PROGRESS FOUNDATION - ASHBURY HOUSE
FACILITY NUMBER:
385600003
ADMINISTRATOR:
ROSANA MARTINEZ
FACILITY TYPE:
772
ADDRESS:
212 ASHBURY STREET
TELEPHONE:
(415) 775-6194
CITY:
SAN FRANCISCO
STATE:
CA
ZIP CODE:
94117
CAPACITY:
20
CENSUS:
0
DATE:
04/28/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:30 PM
MET WITH:
Director of Clinical Administration
TIME COMPLETED:
02:30 PM
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This report is entered by mistake.
SUPERVISORS NAME
:
Julio Montes
LICENSING EVALUATOR NAME
:
Murial Han
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/28/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/28/2022
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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