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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600883
Report Date: 01/22/2024
Date Signed: 01/22/2024 03:08:17 PM

Document Has Been Signed on 01/22/2024 03:08 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:ROSEL'S HOMEFACILITY NUMBER:
415600883
ADMINISTRATOR:JOHN RUZZEL SKAGGSFACILITY TYPE:
735
ADDRESS:2033 OREGON AVENUETELEPHONE:
(650) 387-9488
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 4CENSUS: 4DATE:
01/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Caregiver - Jennifer MinaTIME COMPLETED:
03:15 PM
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On 01/22/2024, Licensing Program Analysts (LPA) Jaime Vado and John Calandra conducted an uannounced case management - other visit. LPA met with Jennifer Mina and explained the purpose of today's visit.

LPAs delivered an immediate exclusion letter to exclude a staff who worked in the facility. According to Jennifer the staff member has been terminated and hasn't been at the facility since terminatio.

The letter was given to and reviewed by the caregiver Jennifer Mina.

This report is reviewed and discussed, and a copy is provided today.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
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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