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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 11/06/2024
Date Signed: 11/06/2024 12:52:37 PM

Document Has Been Signed on 11/06/2024 12:52 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:
11/06/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Caregiver, Linda MondejarTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On November 6, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced plan of correction visit. Upon entrance, LPA met with caregiver, Linda Mondejar, and explained the purpose of today's visit. Caregiver called the administrator/licensee, Anthony Diaz and informed him of LPA's visit.

During the case management visit on 10/23/2024, LPA issued a deficiency under Health and Safety Code 1569.605 as the facility did not have a copy of the current Liability Insurance and the plan of correction was due on 10/25/2024.

On 10/28/2024, the facility Licensees submitted a copy of the Worker’s Compensation and Employer’s Liability Policy from Berkshire Hathaway Guard Insurance Companies and on the 1st page of the liability policy, it stated that the insured period was from May 15, 2024 to May 15, 2025, 12:01AM, the 2nd page, it indicated that name insured was Westborough Manor and the 3rd page, it indicated the facility’s address.

After viewing the insurance policy, LPA proceeded with calling the insurance company and the insurance retailer (Board Spectrum Insurance) for verification and both confirmed that this policy was not active, it was terminated in 2018-2019 due to non-payment and when it was active, it did not cover this facility and it only covered worker's compensation. They also stated that they did not know how the facility’s address appeared on the 3rd page of the policy.

Due to the above observation and deficiency not corrected as the administrator/licensees was not able to provide a copy of the current general liability insurance, a civil penalty is being assess today in the amount of $100 a day from 10/25/2024- 11/6/2024.

A total of civil penalty of $1200 is being assessed today and will continue to accrue until corrected.

This report is reviewed and discussed with the caregiver, Linda Mondejar and licensee, Sheila Diaz over the phone.

A copy of this report and appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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