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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600734
Report Date: 01/24/2024
Date Signed: 01/24/2024 04:28:45 PM

Document Has Been Signed on 01/24/2024 04:28 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:GONZALES HOMEFACILITY NUMBER:
415600734
ADMINISTRATOR:GONZALES, ROGELIO & PROSPEFACILITY TYPE:
740
ADDRESS:3645 FLEETWOOD DRIVETELEPHONE:
(650) 589-8820
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 0DATE:
01/24/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator - Prosperidad GonzalesTIME COMPLETED:
04:30 PM
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On 01/24//2024, San Bruno Regional Office conducted a non-compliance conference meeting with administrator Properidad Gonzales and daughter of licensee and administrator Cherry Gonzales.

Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Managers, Jackie Jin and April Cowan, and Licensing Program Analyst, Jaime Vado.
 
During non-compliance meeting, the following violations were discussed, Administrator Qualifications and Duties, Incidental Dental and Medical Care, Reporting Requirements, Criminal Record Clearance and Associations, Disaster Drills, Storage Space, and Health Related Services.

It is provided during this meeting the amended LIC9099D which contains an additional citation regarding administrator qualifications.

The appealed civil penalties associated to citations regarding Criminal Record Clearances and Associations have been dismissed.

During this meeting, it was discussed, Licensee will receive more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: 
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers
Additional civil penalties for violation resulting in serious bodily injuries are pending review.

Report is reviewed with Prosperidad.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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