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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600734
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:19:45 PM

Document Has Been Signed on 12/16/2024 12:19 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/
DIRECTOR:		GONZALES,PROSPERIDAFACILITY TYPE:
740
ADDRESS:3645 FLEETWOOD DRIVETELEPHONE:
(650) 589-8820
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
12/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Caregiver, Randy BandongTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On December 16, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit. LPA met with caregiver, Randy Bandong and explained the purpose of today's visit. The caregiver called and informed the administrator/licensee of LPA's visit.

The administrator/licensee was available by phone and acknowledged that the Department's Accusations for license revocation has been received.

The administrator/licensee confirmed that the written notice of the accusation was given to residents, their responsible parties and local Ombudsman program.

During today's visit, LPA observed an undated posting of the Dept.'s license revocation action. LPA contacted the responsible parties and all of them acknowledged that they received the notice.

LPA reviewed Health and Safety Code 1569.38 with the administrator/licensee over the phone and the facility will update the posting according to the Health and Safety Code and will provide a copy to CCL by 12/18/2024.

No deficiency cited during today's visit.

This report is reviewed and discussed with the caregiver.

A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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