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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508815
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:02:22 PM

Document Has Been Signed on 08/22/2024 02:02 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:FHAR - SNEATH LANE HOMEFACILITY NUMBER:
410508815
ADMINISTRATOR/
DIRECTOR:		SURDEL, PHILFACILITY TYPE:
735
ADDRESS:3600 SNEATH LANETELEPHONE:
(650) 589-6152
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
08/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator, Phil SurdelTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On August 22, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management- Health and Safety visit to follow up on an incident that was reported by the facility. LPA met with the administrator, Phil Surdel and explained the purpose of today's visit.

On August 19, 2024, facility submitted an incident report to CCL that on August 18, 2024, resident #1 (R1)'s responsible party reported to the facility that R1 sustained fracture ribs and on the report, it indicated that there was an incident that happened on August 15, 2024 between R1 and staff #1(S1) which may resulted R1's injury.

During today's visit, LPA met with R1 and requested documents to be submitted to CCL by 4:30pm today.

No deficiency is cited today. Incident requires further investigation.

This report is reviewed and discussed with the administrator

A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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