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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600420
Report Date: 09/16/2020
Date Signed: 09/16/2020 10:48:08 AM

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:BAUTISTA BOARD AND CARE IFACILITY NUMBER:
415600420
ADMINISTRATOR:BAUTISTA, BLESILDA M.FACILITY TYPE:
740
ADDRESS:708 CIRCLE COURTTELEPHONE:
(650) 873-7261
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 0DATE:
09/16/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bles BautistaTIME COMPLETED:
10:40 AM
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On 9/16/20 Licensing Program Analyst (LPA) Hopkins conducted a facility closure case management inspection via facetime (due to Covid-19 precautions) to verify the facility closure. LPA met with Licensee Bles Bautista and stated purpose of visit.

LPA toured the facility via facetime, touring the kitchen, living room, hallway, and three bedrooms. LPA observed that there are currently no residents at the facility. Bles stated that the last resident moved to independent living a month ago. Bles Bautista stated that she will deliver her closure letter and her license to Community Care Licensing Division (CCLD) San Bruno.

CCLD will be proceeding with the closure. A forfeiture letter will be sent to licensee and the facility number 415600420 shall be closed.

This report was reviewed and emailed to licensee Bles Bautista for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020
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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