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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600863
Report Date: 04/16/2024
Date Signed: 04/16/2024 03:49:23 PM


Document Has Been Signed on 04/16/2024 03:49 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:
04/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Licensee - Armando TriaTIME COMPLETED:
03:45 PM
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On 04/16/2024, Licensing Program Analyst (LPA) Jaime Vado conducted unannounced case management visit in regards to the future of the facility. The licensee requested LPA to come to the facility to discuss.

During today's visit LPA met with the licensee and Rowena Cruz Diaz, licensee of two other homes. According to the licensee he is going to maintain the license and keep the facility vacant until further notice while Rowena goes through the application process and has already notified GGRC to vendorize this facility in order to move her residents from Camenchita's Residential Care Home #415600827 due to the landlord not wanting to extend the lease beyond May or June 2025. She is going to apply for a change of ownership for this location. Armando will remain the licensee and owner of the home and will provide a lease back agreement to Rowena when the time comes. Armando will no longer be accepting residents at this location until the change of ownership is approved under Rowena. LPA advised them to work with Sacramento and the Centralized Applications Branch and to not move residents at this.

No citations issued.

Report reviewed with Armando.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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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