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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600616
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:34:15 PM

Document Has Been Signed on 12/21/2023 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 15DATE:
12/21/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Myralee Casamina, Assistant Administrator and Rosa Diaz, Licensee/AdministratorTIME COMPLETED:
03:40 PM
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On December 21, 2023, Licensing Program Analyst(LPA) John Calandra arrived at the licensed facility to continue the Annual 1-year required visit from November 17, 2023. LPA Calandra met with Assistant Administrator, Myra Casamina.

LPA Calandra interviewed 3 residents and 2 staff. One staff member could not be interviewed due to a language barrier (LPA unable to call language line as he had no phone service.)

No deficiencies were cited during today's visit. A copy of this report was reviewed and provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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