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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600819
Report Date: 07/20/2022
Date Signed: 07/20/2022 01:04:34 PM

Document Has Been Signed on 07/20/2022 01:04 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NORCAL CARE HOME IIFACILITY NUMBER:
415600819
ADMINISTRATOR:GHLICHLOO, FATOLLAHFACILITY TYPE:
740
ADDRESS:1706 BORDEN STREETTELEPHONE:
(650) 376-3461
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 4CENSUS: 4DATE:
07/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Fatollah GhlichlooTIME COMPLETED:
01:15 PM
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On 7/20/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit and met with administrator, Fatollah Ghlichloo and explained the purpose of the visit.

During today's visit, LPA delivered an immediate exclusion letter to exclude an employee at the facility and conducted a health and safety inspection.

The letter was reviewed by the administrator.

This report is reviewed and discussed with administrator. A copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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