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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508691
Report Date: 09/08/2023
Date Signed: 09/08/2023 09:53:11 AM


Document Has Been Signed on 09/08/2023 09:53 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



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:
09/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:TIME COMPLETED:
10:04 AM
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On August 8, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management- closure visit. LPA observed wood, tires, bikes, pipes, children toys in the driveway. There was a car in the driveway, curtains were closed from the front. On the side of the building LPA observed windows open, curtains open, however some parts of the building was taped up. LPA did not observe anyone in the house.

LPA spoke to three neighbors regarding the facility and if they observed any elderly residents in this home. One neighbor indicated that the facility had a for sale sign up a couple months ago and there are new owners. Two neighbors interviewed indicated that the home is no longer operating as a care home and is now a private residence with new owners.

LPA attempted to call the Licensee's facility number and mobile number several times, however both numbers were disconnected. LPA did not observe any residents through the window.

CCLD will be proceeding with the facility closure. A forfeiture letter will be sent to licensee and the facility number 410508691 will be closed.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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