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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 06/06/2023
Date Signed: 06/06/2023 09:51:40 AM

Document Has Been Signed on 06/06/2023 09:51 AM - 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:SAN CARLOS ELMSFACILITY NUMBER:
415600135
ADMINISTRATOR:EVANS, SCOTTFACILITY TYPE:
740
ADDRESS:707 ELM STREETTELEPHONE:
(650) 595-1500
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 130CENSUS: 114DATE:
06/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Scott EvansTIME COMPLETED:
10:00 AM
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On June 6, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on two incidents that were reported to CCLD on 6/5/2023. LPA met with Administrator, Scott Evans and explained the purpose of the visit.

During the visit, LPA reviewed files and obtained copies of pertinent documents in relation to the incident.

This incident requires further investigation.

This report is discussed and reviewed with the Administrator, A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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