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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600654
Report Date: 03/19/2021
Date Signed: 03/19/2021 11:54:15 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:FAMILY AFFAIR CARE HOMEFACILITY NUMBER:
415600654
ADMINISTRATOR:LESLIE, HUI CAOFACILITY TYPE:
740
ADDRESS:264 SOUTHCLIFF AVENUETELEPHONE:
(650) 871-5095
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 0DATE:
03/19/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Hui LeslieTIME COMPLETED:
11:52 AM
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On 3/19/21 Licensing Program Analyst (LPA) Hopkins conducted a facility closure case management inspection via facetime (due to Covid-19 precautions) to verify the facility closure due to facility moving locations. LPA met with Administrator Hui Leslie and stated purpose of visit.

LPA toured the facility via facetime, touring the kitchen, living room, hallway, three bedrooms, and garage. LPA observed that there are currently no residents at the facility. LPA informed Hui Leslie that she needs to forfeit her license for this facility. Hui Leslie agreed and stated that she will forfeit 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 415600654 shall be closed.

This report was reviewed and emailed to Administrator Hui Leslie for signature.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021
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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