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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600080
Report Date:
08/02/2021
Date Signed:
08/02/2021 04:19:32 PM
Document Has Been Signed on
08/02/2021 04:19 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:
SAN MATEO VILLA
FACILITY NUMBER:
415600080
ADMINISTRATOR:
VIDUCICH, ELIZABETH
FACILITY TYPE:
740
ADDRESS:
1661 MCKINLEY STREET
TELEPHONE:
(650) 570-6475
CITY:
SAN MATEO
STATE:
CA
ZIP CODE:
94402
CAPACITY:
6
CENSUS:
3
DATE:
08/02/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:30 PM
MET WITH:
Elizabeth Viducich
TIME COMPLETED:
04:00 PM
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On 8/2/2021 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management tele-inspection to deliver amended report to the facility. LPA met with licensee Elizabeth Viducich and explained purpose of today's tele-inspection.
LPA informed licensee that the LIC9099 complaint report dated 07/19/2021 was in error marked as confidential. LPA Vado explained that the report will now be marked as public and the amended LIC9099 will be sent to the licensee via email. No other changes to the report is being made.
Report is reviewed with the licensee.
No citations issued.
SUPERVISORS NAME
:
Julio Montes
LICENSING EVALUATOR NAME
:
Jaime Vado
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/02/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/02/2021
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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