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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600383
Report Date: 06/13/2024
Date Signed: 06/13/2024 09:27:54 AM

Document Has Been Signed on 06/13/2024 09:27 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:CARE AND CARE RESIDENCE IFACILITY NUMBER:
385600383
ADMINISTRATOR/
DIRECTOR:		JOSE NEVAREZFACILITY TYPE:
740
ADDRESS:940 HAIGHT STREETTELEPHONE:
(415) 829-2775
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY: 14CENSUS: 12DATE:
06/13/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Michelle Perez, Caregiver TIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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On June 13, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:10 AM, to complete the Annual 1-year required inspection. LPA Calandra was greeted by Michelle Perez, Caregiver and explained the purpose of the visit.

LPA Calandra tested the facility's hot water temperature. It was measured at 110.4 degrees Fahrenheit well within the required 105-120 degrees Fahrenheit range.

No deficiencies were cited during today's visit. An exit interview was conducted.

This report was reviewed with Michelle Perez, Caregiver and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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