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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600430
Report Date: 01/04/2021
Date Signed: 01/04/2021 04:01:52 PM

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:CYPRESS AT GOLDEN GATEFACILITY NUMBER:
385600430
ADMINISTRATOR:TAZAWA, KATHERINEFACILITY TYPE:
740
ADDRESS:1601 19TH AVENUETELEPHONE:
(415) 664-6264
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:138CENSUS: 92DATE:
01/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Executive Director, Katherin TazawaTIME COMPLETED:
03:30 PM
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On 1/4/2021, LPA Han conducted an unannounced Case Management Inspection in response to the written document received on 12/25/2020.

Due to the Pandemic, LPA Han has conducted this inspection remotely.

LPA Han interviewed the Administrator, Katherine Tazawa regarding the concern and obtained detail information.

LPA Han requested to following information for R1:

1. Document regarding Responsible Party of resident;
2. Facility's documentation regarding COVID-19
3. Medical Records of resident

Ms. Tazawa stated that the above reports will be provided to San Bruno Licensing Office by 1/5/2020.

LPA Han has reviewed this report with the Administrator, Katherine Tazawa and will provide this report to her for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
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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