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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508691
Report Date: 07/07/2021
Date Signed: 07/07/2021 06:07:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:OUR LADY OF PEACE RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508691
ADMINISTRATOR:SANCHEZ, LOLITA D. QUEFACILITY TYPE:
740
ADDRESS:1669 WOLFE DRIVETELEPHONE:
(650) 574-0498
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 0DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:Lolita SanchezTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with licensee/administrator, Lolita Sanchez.

LPA arrived at the facility at 2:29 PM. At 2:41 PM, LPA toured the facility and inspected all bedrooms. The facility census is currently 0. According to the licensee, they currently have no pending admissions and is currently non-operational. The facility is currently used as a private residence.

LPA advised licensee to inform the Department if they will be accepting new residents and discussed COVID-19 Infection Control requirements including the development of a COVID-19/Epidemic mitigation plan. A copy of the LIC 808 was provided to licensee.

Exit interview conducted and a copy of this report provided to licensee during visit.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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