<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 06/14/2023
Date Signed: 06/15/2023 03:00:12 PM


Document Has Been Signed on 06/15/2023 03:00 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/15/2023 10:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This is an amended report.

On this day Licensing Program Analyst (LPA) Grace Donato and Investigator Victoria McIntosh conducted an unannounced visit. LPA and Investigator met with Administrator, William Encarnacion and explained the purpose of the visit.

The purpose of today's visit is to deliver an immediate exclusion letter to exclude a nonclient adult resident of the facility.

The letter was given and reviewed by the Administrator.

This report is reviewed and discussed with the Administrator and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1