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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600616
Report Date: 05/20/2021
Date Signed: 05/20/2021 12:41:15 PM

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:NEW CEDAR LANE CARE HOME, INC.FACILITY NUMBER:
415600616
ADMINISTRATOR:DIAZ, YOLANDAFACILITY TYPE:
740
ADDRESS:924 CEDAR STREETTELEPHONE:
(650) 728-3132
CITY:MONTARASTATE: CAZIP CODE:
94037
CAPACITY:17CENSUS: 11DATE:
05/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yolanda DiazTIME COMPLETED:
12:45 PM
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LPA Jeung and LPA Han provided Technical Support to the Administrator during complaint investigation.

Signs should be posted at entry gate directing visitors to the central entry point--which is on the side of the house--for proper COVID screening.

COVID related signs are not present, such as cough etiquette, face covering, social distancing, etc. COVID related signs must be prominently posted throughout the facility.

Hand-washing reminder instructions signs are not present in all bathrooms and sinks.

LPA Jeung will email COVID-19 signs to the Administrator.

Administrator is reminded of the following:

- Review and implement elements of facility COVID Mitigation Plan
- All unusual incidents which threaten the health and safety of residents and staff must be reported to CCLD mandated time frame, in accordance with Section 87211 Reporting Requirements.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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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