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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 10/23/2024
Date Signed: 10/23/2024 12:17:54 PM

Document Has Been Signed on 10/23/2024 12:17 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:WESTBOROUGH MANOR 6FACILITY NUMBER:
415600848
ADMINISTRATOR/
DIRECTOR:		TERCIANO, BELLAFACILITY TYPE:
740
ADDRESS:2550 CATALPA WAYTELEPHONE:
(650) 875-9016
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 5DATE:
10/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Caregiver, Linda MondejarTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On October 23, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management- Other visit to obtain a copy of the current Liability Insurance. LPA met with caregiver, Linda Mondejar and explained the purpose of today's visit.

During the facility annual inspection on 8/22/2024, LPA requested for a copy of the current liability insurance, and on 8/23/2024, LPA reminded the licensee in writing for a copy of the liability insurance.

During a case management visit on 10/17/2024, the Licensees/administrator stated that they did not have a copy of the liability insurance at the facility and they would provide a copy by 10/18/2024.

As of today, the Licensees did not provide a copy of the liability insurance.

During today's visit, caregiver called the licensees/administrator who stated that they did not have a copy of the current liability insurance and that they would work on it and provide a copy by 10/25/2024,

Deficiency is cited under Health and Safety Code, Title 22 Division 6 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with caregiver, Linda Mondejar in person and administrator/licensee, Anthony Diaz on the phone. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 10/23/2024 12:17 PM - It Cannot Be Edited


Created By: Murial Han On 10/23/2024 at 12:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WESTBOROUGH MANOR 6
FACILITY NUMBER: 415600848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
HSC
1569.605

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1569.605
Liability insurance; coverage requirements...
Based on interview, observation and record reveiw, This requirement is not met as evidenced by the facility did not provide a copy of the
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The administrator/licensee will provide a copy of the current liability insurance to CCL by 10/25/2024.
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current liability insurance after several verbal and written reminders which poses a potential risk to residents 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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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