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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 03/30/2023
Date Signed: 03/30/2023 02:36:42 PM


Document Has Been Signed on 03/30/2023 02:36 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:WESTBOROUGH MANOR 6FACILITY NUMBER:
415600848
ADMINISTRATOR:TERCIANO, BELLAFACILITY TYPE:
740
ADDRESS:2550 CATALPA WAYTELEPHONE:
(650) 875-9016
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
03/30/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Bella TercianoTIME COMPLETED:
02:45 PM
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LPAs Jeung and Donato met with administrator Bella Terciano, staff and residents, toured facility and inspected food and PPE supplies. LPAs were screened upon entry for COVID precautions.

LPAs advised Ms. Terciano about the following:

- Control of property cannot be verified, as lease on file expired 2/28/23 and must be renewed immediately
- Status of licensee Senior Care Cornerstone, Inc. is suspended since 2017 and must be revived immediately

LPAs spoke with Anthony Diaz, CEO of Senior Care Cornerstone, Inc. by phone and advised him to address the above mentioned items and notify LPAs upon correction/completion..

Facility temperature is comfortable, lighting is sufficient for safety, and clients appeared well groomed. Food supply is adequate and meets minimum requirements for 2-day fresh and 7-day perishable supplies.

No deficiencies cited today.



SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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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