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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600616
Report Date: 06/15/2021
Date Signed: 06/15/2021 12:32:36 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: 9DATE:
06/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Rosa DiazTIME COMPLETED:
12:45 PM
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 6/15 /21 Licensing Program Analyst (LPA) Murial Han conducted an unannounced inspection and met with the Administrator, Rosa Diaz. LPA explained the purpose of the visit and delivered this finding.

During the investigation of complaint control number 14-AS-20210601132624, LPA reviewed the Admission Agreement for Resident (R2) who was admitted with a cat, but the Admission Agreement did not include pet policy.

After the admission, the facility developed an Addendum addressing the Pet Deposit and Monthly Pet Service Charge but it was not completed for R2.

A Technical Violation was issued. No deficiencies were cited at this time.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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