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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600024
Report Date: 07/21/2022
Date Signed: 07/21/2022 10:53:04 AM

Document Has Been Signed on 07/21/2022 10:53 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:PETER CLAVER COMMUNITYFACILITY NUMBER:
385600024
ADMINISTRATOR:TONJA SAGUNFACILITY TYPE:
736
ADDRESS:1340 GOLDEN GATE AVENUETELEPHONE:
(415) 749-3800
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY: 32CENSUS: 19DATE:
07/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Winitu WoldeysusTIME COMPLETED:
10:55 AM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit to receive documents regarding a resident suicide. LPA explained purpose of today's visit to facility LVN Winitu.

Around 1020am LPA spoke to facility administrator Tonja Sagun via telephone and explained the purpose of today's visit as well.

LPA Vado requested from Tonja pertinent documents for R1 such as admission agreement, intake assessments, care plan, and/or any notes staff may have recorded regarding resident behavior or observations. LPA also requested if the staff were provided a case number from the police department that it be shared with LPA. She indicated no report was provided but will check with staff if a case number was provided. Tonja indicated that she will send these items via email to LPA Vado by no later than tomorrow 7/22/2022. LPA and Tonja confirmed LPA's email address for sending.


Report is reviewed with Tonja via telephone and is being signed by facility LVN Winitu.

No citations issued
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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