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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600359
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:39:28 PM


Document Has Been Signed on 05/31/2024 02:39 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CARLISLE-IVY SIGNATURE LIVING, THEFACILITY NUMBER:
385600359
ADMINISTRATOR:STEPHANIE SCHMAUTZFACILITY TYPE:
740
ADDRESS:1450 POST STTELEPHONE:
(415) 929-0200
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:130CENSUS: 89DATE:
05/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Jeffrey Brenner, Executive Director TIME COMPLETED:
02:45 PM
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On May 31, 2024 at 2:08 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a case management visit regarding an item that had been previously reported as missing in February 2024. LPA Calandra was greeted by Jeffrey Brenner, Executive Director and explained the purpose of the visit.

LPA Calandra reviewed 1 resident record and obtained a copy of R1's, Statement of property and valuables.

No deficiencies were cited during today's visit.

This report was reviewed with Jeffrey Brenner, Executive Director and a copy of the report left at the facility.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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