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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508725
Report Date: 10/14/2025
Date Signed: 10/14/2025 10:05:53 AM

Document Has Been Signed on 10/14/2025 10:05 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:C AND Z RESIDENTIAL CAREFACILITY NUMBER:
410508725
ADMINISTRATOR/
DIRECTOR:		HERRERA, CESAR DE JESUSFACILITY TYPE:
735
ADDRESS:636 SOUTHMOOR DRIVETELEPHONE:
(650) 355-3317
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 10CENSUS: 6DATE:
10/14/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Mayra Herrera and Cesar Herrera, LicenseesTIME VISIT/
INSPECTION COMPLETED:
10:10 AM
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On 10/14/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management-Health Check. LPA Calandra was greeted by Mayra Herrera(Licensee) and explained the purpose of the visit. Cesar Herrera arrived later during the visit.

LPA toured the physical plant. This is a 2-story building with 7 bedrooms, 3 bathrooms, a storage area, dining room, laundry room, kitchen, family room, and storage area. No accessible bodies of water or hazards were observed in hallways or the front or backyards. The facility was maintained at a comfortable temperature.

LPA reviewed 2 resident files. All were observed to be complete.

LPA received a copy of the current resident roster as of 10/14/2025 and LIC 500 personnel summary report.

No deficiencies cited during today's visit.

An exit interview was conducted. This report was reviewed with facility representatives and a copy provided.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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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