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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600388
Report Date: 02/28/2022
Date Signed: 02/28/2022 01:47:14 PM


Document Has Been Signed on 02/28/2022 01:47 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:IDA'S REST HOME, LLCFACILITY NUMBER:
385600388
ADMINISTRATOR:YEE, MARGARET J.FACILITY TYPE:
740
ADDRESS:612 39TH AVENUETELEPHONE:
(415) 751-1029
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:11CENSUS: 0DATE:
02/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Margaret YeeTIME COMPLETED:
02:00 PM
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On 2/28/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit regarding the facility closure. LPA rang the doorbell and met with the Administrator, Margaret Yee and LPA explained the purpose of the visit.

LPA toured the facility and grounds.There are total of 7 bed rooms (4 downstairs and 3 upstairs) and LPA verified that there are no residents in care or residing at this location. All the rooms, the drawers and the closets were empty; and the entire kitchen is under renovation. All residents have been moved to other long term care facilities.

CCLD will be proceeding with the closure. A forfeiture letter will be sent to licensee to the facility's address and the facility number 385600388 shall be closed.

LPA discussed the report with the Administrator, Margaret Yee.

A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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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