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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508835
Report Date: 06/09/2022
Date Signed: 06/09/2022 12:27:39 PM


Document Has Been Signed on 06/09/2022 12:27 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:KARINA CARE HOMEFACILITY NUMBER:
410508835
ADMINISTRATOR:CARDOZA, CORINAFACILITY TYPE:
740
ADDRESS:214 SANDPIPER COURTTELEPHONE:
(650) 377-0821
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:6CENSUS: 0DATE:
06/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator/Licensee, Corina CardozaTIME COMPLETED:
12:35 PM
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On June 9, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted a facility closure case management inspection to verify the facility closure. LPA met with Licensee/Administrator Corina Cardoza, and explained the purpose of the visit. CCL Office received a closure notice on June 1, 2022..

The Licensee provided a tour of the facility. During the tour, LPA observed the kitchen, living room, dining room, 6 bedrooms, 2 bathrooms, backyard, closets, and garage. LPA observed that there are currently no residents at the facility.

Licensee informed CCL of facility closure by letter. LPA did not observe any residents and did not observe evidence of care and supervision In the home.

CCLD will be proceeding with the closure. A forfeiture letter will be sent to licensee and the facility number 410508835 shall be closed.

This report is reviewed, and discussed with the Licensee, and a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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