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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 11/19/2024
Date Signed: 11/19/2024 12:59:37 PM

Document Has Been Signed on 11/19/2024 12:59 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:
11/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Caregiver, Ferdinand BambaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 11/19/2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced plan of correction visit. LPA met with caregiver, Ferdinand and explained the purpose of today's visit. Caregiver called the co-licensee, Sheila Diaz to inform LPA's visit and LPA explained the purpose of today's visit to the co-licensee over the phone.

On 11/6/2024, facility received a civil penalty for not having a copy of the current General Liability Insurance and the civil penalty was assessed from 10/25/2024- 11/6/2024 in the amount $1200 ($100 per day).

On 11/15/2024, LPA received a copy of the current General Liability Insurance.

During today visit, an additional civil penalty is being assessed from 11/7/2024 - 11/14//2024 in the amount of $800 ($100 per day) and civil penalty has been stopped on 11/15/2024 as the citation has been corrected.

This report is reviewed and discussed in person with the caregiver and on the phone with the co-licensee.

A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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