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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 411408916
Report Date: 09/20/2023
Date Signed: 09/20/2023 04:14:40 PM

Document Has Been Signed on 09/20/2023 04:14 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:SHOREVIEW HOMEFACILITY NUMBER:
411408916
ADMINISTRATOR:ADORA ANCHETAFACILITY TYPE:
735
ADDRESS:1793 SHOREVIEW AVE.TELEPHONE:
(650) 340-0270
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 6DATE:
09/20/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Adora Ancheta and Ana ManlaTIME COMPLETED:
04:30 PM
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LPA Jeung followed up on citations issued on 8/31/23 and 7/24/23--for which corrections had not been submitted by due dates--and civil penalty assessments issued on 9/11/23:

80019 Criminal Record Clearance
Civil penalty of $500 was issued to assess $100/day x 5 days.
Criminal record clearance for staff AM is not maintained according to Dept. records and plan or proof of corrections was not received by due date 9/1/23 to adequately correct this deficiency.

80065 Personnel Requirements
Civil penalty of $300 was issued to assess $100/day x 3 days, 9/8 - 9/10/2023. As per Civil Penalty Assessment form LIC 421FC, civil penalty of $100 per violation per day shall be assessed until the violation is corrected.
Health screening and/or TB test results for staff AM is now maintained and copies are provided today. Plan or proof of corrections was not received by due date 9/7/23.

Plan or proof of corrections was received in regional office on 9/14/23. However, LPA was not in receipt of proof of correction until today, when clerical staff confirmed receipt.
Staff AM has criminal record clearance as of 9/13/23 and health screening for staff AM was faxed to CCLD on 9/14/23.
Civil penalty of $200 is assessed for period 9/11 to 9/13/23, which represents $100/day x 3 days.
See LIC 421FC.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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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