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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508554
Report Date: 11/18/2022
Date Signed: 11/18/2022 05:56:13 PM

Document Has Been Signed on 11/18/2022 05:56 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RUSTAN ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508554
ADMINISTRATOR:RUIZ, NECITAFACILITY TYPE:
735
ADDRESS:147 PLYMOUTH CIRCLETELEPHONE:
(650) 878-8297
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 0DATE:
11/18/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:16 PM
MET WITH:Administrator, Leah RuizTIME COMPLETED:
06:00 PM
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On 11/18/2022, Licensing Program Analyst conducted an unannounced Health Checks to ensure all clients are relocated to another designation as the facility had a fire in the garage on Wednesday, 11/16/2022.

LPA called the administrator and explained the purpose of today's visit. The administrator reported all the residents and staff were safely evacuated, and 911 was called.

In addition, the administrator reported that the facility was able to retrieve resident's medical records, medications, and files with them to the new location.

During the visit, LPA observed the entire garage door was covered with a big wood board with some blackish color on top, one of the windows on the side of the facility has a screen that is detached from the window frame with some blackish color on top, LPA observed it was dark inside the facility through a window next to the garage dooe, LPA rang the door bell, knocked on the door and no one answered.

This report is reviewed and discussed with the administrator over the phone as the administrator was not available to do it in person.

A copy of this report will be provided to the administrator via email.


SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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