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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508913
Report Date: 09/21/2021
Date Signed: 09/21/2021 11:16:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:FOSTER CITY CARE HOMEFACILITY NUMBER:
410508913
ADMINISTRATOR:SALARIOSA, PERRINEFACILITY TYPE:
740
ADDRESS:280 STILT COURTTELEPHONE:
(650) 349-4080
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:6CENSUS: 5DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Perrine SalariosaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Perrine Salariosa.

During visit, LPA toured the indoor and outdoor areas of the facility. LPA Marrufo observed the visitor screening area at the central facility entrance. LPA observed 2 out of 2 resident bathrooms and observed there to be available soap for hand washing. LPA observed the facility kitchen area and observed the pantry area as well. LPA toured the PPE supplies in the facility office and in the garage. COVID-19 related posters were observed throughout the facility hallways. The facility outdoor exits were observed to be free of obstructions.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Perrine Salariosa and a copy of the report was provided.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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