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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600715
Report Date: 08/31/2022
Date Signed: 08/31/2022 06:53:27 PM


Document Has Been Signed on 08/31/2022 06:53 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HOME IN BURLINGAME, THEFACILITY NUMBER:
415600715
ADMINISTRATOR:RELEVO, I. & HADUCA MA. E.FACILITY TYPE:
740
ADDRESS:922 CAPUCHINO AVENUETELEPHONE:
(650) 348-1079
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:6CENSUS: 0DATE:
08/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:NATIME COMPLETED:
10:30 AM
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 this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit to confirm that the facility is closed and vacant of residents. Prior to visiting the facility to make observations LPA called the facility but the phone number did not work. LPA then emailed the registered email designated for the facility but did not receive a response.

Upon arriving to the facility LPA observed someone carrying construction materials to the backyard from a truck. LPA attempted to question the worker but he did not speak english and could not answer LPAs questions. The windows facing the street of the facility were covered in paper. LPA knocked and looked through the glass on the front door and observed that remodeling was taking place. Plastic sheeting, new flooring, and other constructing materials are observed. Through another window adjacent to the door LPA observed more construction materials. The facility is empty as observed.

No one is present at facility to sign this report.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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