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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600806
Report Date: 01/19/2024
Date Signed: 01/19/2024 11:39:44 AM


Document Has Been Signed on 01/19/2024 11:39 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:HARMONY ASSISTED LIVING OF SAN MATEOFACILITY NUMBER:
415600806
ADMINISTRATOR:SANDOVAL, TERRIFACILITY TYPE:
740
ADDRESS:1818 ROYAL AVENUETELEPHONE:
(650) 212-0244
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 0DATE:
01/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Alfredo SandovalTIME COMPLETED:
11:45 AM
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In response to written notice received on 1/10/24 that facility is closed and has no residents, LPA Jeung inspected 3 bedrooms to confirm that there are no residents in care.

RCFE license has been returned to CCLD.

Forfeiture letter is forthcoming.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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