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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600863
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:43:24 PM

Document Has Been Signed on 03/19/2024 03:43 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:A & E HOME CARE SERVICESFACILITY NUMBER:
415600863
ADMINISTRATOR:TRIA, ARMANDO Z.FACILITY TYPE:
740
ADDRESS:1615 DIX STREETTELEPHONE:
(650) 574-5994
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 0DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator - Armondo TriaTIME COMPLETED:
03:30 PM
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On 03/19/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with administrator Armando Tria and explained the purpose of today's visit.

This is a one level facility. According to Armando the facility is vacant and there are no resident's as of last year. LPA conducted the inspection and observed no residents in care. Resident files are still on site as well as staff. The facility is in good condition, all utilities connected, food supplies in place, and maintained ready for residents to move in should he accept more. There are no medications or belongings of any residents in the facility. He says he is still interested in keeping his license at this time and will reach back out to LPA in April regarding the future of the facility and the license. He says he intends to keep it for now.

The following updated items are requested to be sent to the Department:

• LIC610E Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Proof of control of property


No citations issued.

Report reviewed with administrator Armando Tria.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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