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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600744
Report Date: 02/16/2024
Date Signed: 02/16/2024 12:59:06 PM


Document Has Been Signed on 02/16/2024 12:59 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:APPLE TREE HOME CAREFACILITY NUMBER:
415600744
ADMINISTRATOR:HUANG, WENSHUFACILITY TYPE:
740
ADDRESS:716 NORTH HUMBOLDT STREETTELEPHONE:
(650) 376-3389
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
02/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joebelle Payumo and Lilia MauricioTIME COMPLETED:
01:00 PM
NARRATIVE
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During pre-licensing inspection visit for change of ownership to TLC Home Care V, LPA Jeung observed deficiency of the California Code of Regulations, Title 22. Deficiency is cited on a following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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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Document Has Been Signed on 02/16/2024 12:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: APPLE TREE HOME CARE
FACILITY NUMBER: 415600744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
87355(c)(1)

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CRIMINAL RECORD CLEARANCE
A licensee or applicant...may request a transfer of a criminal record clearance from one state licensed facility to another...by providing the following documents to the Dept: a signed Criminal Background Clearance Transfer Request (LIC 9182),
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 Criminal Background Clearance Transfer Request (LIC 9182) is completed and given to LPA with copy of photo identification
Deficiency corrected and cleared
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a copy of the individual's driver's license.
This requirement was not met, as staff A.L. does not have clearance associated to this facility, which poses an immediate health, safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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