<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 06/07/2023
Date Signed: 06/08/2023 11:18:59 AM


Document Has Been Signed on 06/08/2023 11:18 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: DATE:
06/07/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Scott EvansTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On June 8, 2023 San Bruno Regional Office conducted a non-compliance conference meeting with Administrator, Scott Evans and Attorney, Joel Goldman.

Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, Cara Smith, and Licensing Program Analyst, Komal Charitra.

During non-compliance meeting, the following violations were discussed, Additional Personal Rights of Residents in Privately Operated Facilities for Licensee failing to provide care, supervision and services that met Resident 1 (R1’s) needs that resulted in serious bodily injury sustained by R1.

During this meeting, it was discussed, Community Care Licensing will increase frequency monitoring inspection visits to ensure compliance with this compliance plan of Title 22 regulation. Licensee was provided the link below for resources and guidance to improve facility operations:
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers

The Administrator was informed that additional civil penalties may be assessed, pending review. Report is reviewed with the Administrator and a copy is provided via email. Administrator to sign report and submit to LPA by 6/8/23.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1