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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600162
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:25:56 AM

Document Has Been Signed on 12/22/2022 11:25 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:ISMAELA'S HOME CARE, INC.FACILITY NUMBER:
415600162
ADMINISTRATOR:PEREDO, RADIGONDEFACILITY TYPE:
740
ADDRESS:468 HAZEL AVENUETELEPHONE:
(650) 615-9937
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 5DATE:
12/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Charito Rafael and Florinda GuintoTIME COMPLETED:
11:30 AM
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LPA Jeung met with staff to obtain update on licensee/administrator Rady Peredo.

LPA also discussed options for the facility moving forward, as the viability of corporation is questionable.

CCR 87411 (f) Personnel Requirements and CCR 87205 Accountability of Licensee Governing Body are reviewed with Ms. Guinto.

Updated health screening for licensee is requested to be submitted to CCLD by 12/28/22.

Acknowledgement of corrected deficiency cited on 11/17/22 is given to staff--1 page.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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