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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600452
Report Date: 01/29/2024
Date Signed: 01/29/2024 04:24:37 PM

Document Has Been Signed on 01/29/2024 04:24 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GROVE STREET HOUSEFACILITY NUMBER:
385600452
ADMINISTRATOR:NATALIE PAULINSKAFACILITY TYPE:
772
ADDRESS:2157 GROVE STREETTELEPHONE:
(415) 387-2275
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY: 9CENSUS: 0DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jeremy Tsuchitani-Watson TIME COMPLETED:
12:00 PM
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On 1/29/2024, Licensing Program Analyst (LPA) Grace Donato conducted an annual visit. LPA met with Associate Chief Clinical Officer Jeremy Tsuchitani-Watson and explained the purpose of the visit.

During the visit, it was observed that the facility is still non-operational and has been closed. No staff and no client/resident files in the facility. Facility is being prepped for reopening but no specific date yet. First Aid Kit is still current. Facility has a pull alarm fire system, fire extinguisher(s), smoke and carbon monoxide detectors,

Once the facility reopens the following documents are to be submitted:
Any addendums to the Infection Control Plan
Control of Property
Designation of Facility Responsibility (LIC308)
Administrative Organization (LIC 309)
Personnel Report (LIC500) to include the Administrator presence in the facility
Emergency Disaster Plan (LIC610D)

No deficiencies being cited today. A report is reviewed and copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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