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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600277
Report Date: 07/01/2025
Date Signed: 07/01/2025 11:24:06 AM

Document Has Been Signed on 07/01/2025 11:24 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SFAL - THE AVENUEFACILITY NUMBER:
385600277
ADMINISTRATOR/
DIRECTOR:		WONG, TERESAFACILITY TYPE:
740
ADDRESS:1035 VAN NESS AVENUETELEPHONE:
(415) 776-1800
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY: 145CENSUS: 0DATE:
07/01/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:26 AM
MET WITH:Teresa Wong, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 7/1/2025, Licensing Program Analyst (LPA) Tobola arrived at this facility for the purpose of conducting a closure inspection pursuant to voluntary closure of this licensed Residential Care Facility for the Elderly and was greeted by Administrator, Teresa Wong.

LPA conducted a walk-through of the facility, inspected resident rooms and common spaces of the building. There are currently no residents living in the facility and with the last residents moved out on 6/24/2025. LPA was provided with a list of all residents and relocation sites and given updates throughout the month leading up to the final closure. During today's inspection LPA found no evidence that would suggest that any residents are residing on the premises. Administrator stated that residents have taken selected personal belongings and furnishings for transfer to their new resident locations. Any additional furnishing items within rooms were either owned by the facility or planned for donation. The facility files for both residents and staff are in the process of consolidation and are to be transferred to a relocation site/storage for the duration of Title 22 requirements.

The Licensee initiated this facility closure and submitted a written statement to Community Care Licensing (CCL) on 5/29/2025, requesting to close this facility. The facility Administrator provided full assistance with resident assessments, determining appropriate relocation sites and transportation to ensure ease of transfer. All residents were found to be safely relocated. In addition, LPA was provided copies of each residents' signed termination of admission.

Closure inspection of this facility has been completed. Facility has surrendered the license to LPA Tobola. The Department will be moving forward with the closure process. LPA Tobola to finalize paperwork for final closure. No deficiencies cited.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Dominic Tobola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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