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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410507207
Report Date: 03/29/2024
Date Signed: 03/29/2024 05:05:31 PM

Document Has Been Signed on 03/29/2024 05:05 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:P.A.R.C.A. CEDAR STREET HOUSEFACILITY NUMBER:
410507207
ADMINISTRATOR:CARLETTE L PHIPPSFACILITY TYPE:
735
ADDRESS:721 CEDAR STREETTELEPHONE:
(650) 226-3798
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 8CENSUS: 7DATE:
03/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Marites Dela CruzTIME COMPLETED:
04:15 PM
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On 3/29/24, LPA Grace Donato conducted an unannounced case management visit regarding an incident reported on 3/28/24. LPA met with Interim Administrator (ADM), Marites Dela Cruz and explained the purpose of the visit.

Concerning the incident report that was reported to Licensing about a former employee who embezzled money from the facility. Licensee will email documentation to LPA with regards to money taken.

Employee is no longer connected with the facility. A police report has been filed.

No deficiencies is being cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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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