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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 01/28/2025
Date Signed: 01/28/2025 11:18:45 AM

Document Has Been Signed on 01/28/2025 11:18 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:
01/28/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Caregiver, Lirio HernandezTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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On 1/28/2025, Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management visit. LPA met with caregiver, Lirio Hernandez and explained the purpose of today's visit.

During today visit, LPA provided an invoice of a civil penalty that the facility was assessed on 11/19/2024 in the amount of $800 as the mail was "Return To Sender". LPA also spoke to the Licensee, Sheila Diaz over the phone who requested CCL to change the facility's mailing address to the facility's address.

No deficiency is cited today.

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: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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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