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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600821
Report Date:
07/01/2022
Date Signed:
07/01/2022 04:03:46 PM
Document Has Been Signed on
07/01/2022 04:03 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:
HOME SWEET HOME SENIOR CARE
FACILITY NUMBER:
415600821
ADMINISTRATOR:
NEDILJKA MATIJAS
FACILITY TYPE:
740
ADDRESS:
1560 BRYANT STREET
TELEPHONE:
(650) 992-2727
CITY:
DALY CITY
STATE:
CA
ZIP CODE:
94015
CAPACITY:
55
CENSUS:
32
DATE:
07/01/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
04:00 PM
MET WITH:
Devin Corey
TIME COMPLETED:
04:10 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit to deliver amended complaint investigation report LIC9099. LPA met with assistant administrator Devin Corey.
LPA hand delivered amended LIC9099 dated on this day reflecting the change of the report from confidential to public viewing to Devin.
No citations issued.
Report reviewed with Devin.
SUPERVISOR'S NAME:
Julio Montes
TELEPHONE:
(650) 266-8811
LICENSING EVALUATOR NAME:
Jaime Vado
TELEPHONE:
(559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2022
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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