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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600735
Report Date: 08/30/2023
Date Signed: 08/31/2023 07:43:37 AM


Document Has Been Signed on 08/31/2023 07:43 AM - 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:DOUBLE HAPPINESS CARE HOMEFACILITY NUMBER:
415600735
ADMINISTRATOR:LAU, FLORDELIZAFACILITY TYPE:
740
ADDRESS:859 CAMARITAS CIRCLETELEPHONE:
(650) 993-4018
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 4DATE:
08/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Irene Mehta & Flordeliza LauTIME COMPLETED:
02:00 PM
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On 8/30/2023, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced health and safety case management visit. LPA met with Irene Mehta, Facility Owner and Flordeliza Lau, Licensee. LPA explained the purpose of the visit.

LPA observed that residents have just finished lunch and are currently resting. Facility area surroundings are clean. Everything is in order inside the facility.

Both the facility owner and Licensee are working together collaboratively together to ensure the health and safety of the residents in care. Licensee is working with the new owner until she gets her own license.

No deficiencies cited today.

Report was discussed and a copy of the report is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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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