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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 10/17/2024
Date Signed: 10/17/2024 10:59:47 AM

Document Has Been Signed on 10/17/2024 10:59 AM - 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:
10/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Caregiver, Linda MondejarTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On October 17, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management- Other visit to obtain a signature for a civil penalty that was assessed on 3/23/2021. LPA met with caregiver, Linda Mondejar and explained the purpose of today's visit.

After entrance, LPA called and spoke to the Licensee who was able to recall the time when the civil penalty was issued and authorized the caregiver to sign the Civil Penalty Assessment.

The original Civil Penalty Assessment report was provided to the caregiver.

This report is reviewed and discussed with the caregiver.

A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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