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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410500567
Report Date: 03/07/2025
Date Signed: 03/07/2025 11:07:35 AM

Document Has Been Signed on 03/07/2025 11:07 AM - 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:SEQUOIAS-PORTOLA VALLEY, THEFACILITY NUMBER:
410500567
ADMINISTRATOR/
DIRECTOR:		APRIL THOMPSONFACILITY TYPE:
741
ADDRESS:501 PORTOLA ROADTELEPHONE:
(650) 851-1501
CITY:PORTOLA VALLEYSTATE: CAZIP CODE:
94028
CAPACITY: 328TOTAL ENROLLED CHILDREN: 0CENSUS: 258DATE:
03/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:David Nelson, Director of Clinical Services TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 3/7/2025, Licensing Program Analysts(LPAs) John Calandra and Yi Sam Jian, arrived at the facility to conduct a Case Management visit in regards to a self-reported incident report received by the Department on 2/25/2025, regarding a resident who sustained multiple fractures. LPAs were greeted by David Nelson, Director of Clinical Services.

LPAs received copies of the following documents:

- Care notes for R1
- LIC 602: Physician's Report for R1
- Service Plan for R1
- Admissions Agreement

No deficiencies cited during today's visit.

An exit interview was conducted. This report was reviewed with David Nelson, Director of Clinical Services and a copy of the report provided.



Andrea MedlinTELEPHONE: (650) 266-8811
John CalandraTELEPHONE: 650-266-8800
DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
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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