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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600858
Report Date: 01/23/2024
Date Signed: 01/23/2024 10:16:50 AM

Document Has Been Signed on 01/23/2024 10:16 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HERITAGE ROYALEFACILITY NUMBER:
415600858
ADMINISTRATOR:DELA CRUZ, ANICIAFACILITY TYPE:
740
ADDRESS:2 HENRY PLACETELEPHONE:
(650) 697-8930
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 5DATE:
01/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anna Villanueva-AoayTIME COMPLETED:
10:30 AM
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As per initial annual inspection on 1/19/24, LPA Jeung provided amended Facility Evaluation Report . Due to technical difficulties on 1/19/24, first page of Facility Evaluation Report was inaccurate.

Amended page 1 of Facility Evaluation Report is provided, along with additional 3 pages of Advisory Notes. There are no changes or amendments to subsequent pages of Report of 1/19/24.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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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