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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508913
Report Date: 09/13/2022
Date Signed: 09/13/2022 02:40:03 PM


Document Has Been Signed on 09/13/2022 02:40 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



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: 0DATE:
09/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 AM
MET WITH:TIME COMPLETED:
02:40 PM
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On 9/13/22, Licensing Program Analyst (LPA), Murial Han conducted an unannounced visit for a facility closure inspection. LPA Han arrived at the facility at 12:30 pm and rang the door bell several times but no one answered. LPA knocked on the side door and the window sliding door and there was no answer as well.

LPA observed furniture by the front entrance such as a cream sofa covered with floral print linen with black leather cushions on top, and a wooden table with 4 chairs around it.

LPA walked around the facility and pee through one of the windows and observed many boxes stacked on top of each other.

LPA Han called and spoke to the administrator, Perrine Salariosa who stated that the last resident was discharged on June 30, 2022.

According to the administrator, facility license was surrender on July 22, 2022 and mailed back together with the notification of certification of non-operation.

CCLD will be proceeding with the closure as administrator/licensee confirmed that administrator/licensee is no longer interested in maintaining a license.

A forfeiture letter will be sent to administrator/licensee and the facility number 410508913 shall be closed.

Administrator not present during the inspection. This report is reviewed, and discussed with the administrator on the phone.

A copy of this reported will be emailed and mailed to the administrator.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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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