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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600417
Report Date: 12/21/2023
Date Signed: 02/02/2024 03:11:20 PM


Document Has Been Signed on 02/02/2024 03:11 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/02/2024 09:23 AM

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

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**THIS IS AN AMENDED REPORT**


On December 21, 2023, Licensing Program Analyst(LPA) John Calandra and Licensing Program Manager, Cara Smith conducted an attempted unannounced case management health check visit in relation to the facility sending a check to Sacramento that bounced for the Annual fee, the facility phone number being no longer in service, and being unable to contact the property manager and Administrator.

LPA and LPM knocked on the door once, and a woman answered the door. LPA Calandra and LPM Smith introduced themselves and explained the purpose of their visit. The woman, Rose Caspillian is a caretaker at the facility. Rose informed LPA Calandra and LPM Smith that she and her husband, Jerry Caspillian are the only staff working today. LPA and LPM asked if the Administrator was available and were told that Rose could call him. The LPA and LPM talked to the administrator and explained the purpose of their visit over the phone. Based on an interview with the Administrator, they stated that the bank account did not have funds to cover the Annual fee. Thus, when they were notified by mail that the check had bounced, the Administrator wrote another check. LPA obtained an updated phone number and email address for the facility and was told by the Administrator that they have sent a second check to Sacramento for the annual fee. Review of the department system shows that the check was paid. LPA and LPM were given a tour of the facility by Rose. The facility consists of 5 bedrooms and 2 bathrooms, a kitchen, living room, and dining room.

No deficiencies cited during today's visit. A copy of the report was reviewed with Rose Caspillian and left at the facility.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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