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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:28:06 PM

Document Has Been Signed on 05/15/2023 02:28 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: 0DATE:
05/15/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Anthony Diaz and Sheila DiazTIME COMPLETED:
02:40 PM
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On May 15, 2023 San Bruno Regional Office conducted a non-compliance conference meeting with Licensee, Anthony Diaz and Sheila Diaz.

Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, Jackie Jin, and Licensing Program Analyst, Komal Charitra.
 
During non-compliance meeting, the following violations were discussed, Incidental Medical and Dental Care for licensee failing to ensure to seek timely medical attention resulting in Resident (R1) sustaining serious bodily injury and Storage Space for licensee falling to ensure chemicals and toxins were locked.

In addition, during the non-compliance meeting, Regional Manager, Vivien Helbling hand delivered a copy of the denied appeal response from the appeal that was made by the Licensee on 4/7/2021.

During this meeting, it was discussed, Community Care Licensing will increase frequency monitoring inspection visits to ensure compliance with this compliance plan of Title 22 regulation.  licensee was provided the link below for resources and guidance to improve facility operations: 
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers

The Licensee was informed that additional civil penalties may be assessed, pending review. Report is reviewed with the Licensee and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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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