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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600883
Report Date: 03/22/2024
Date Signed: 03/22/2024 02:15:20 PM

Document Has Been Signed on 03/22/2024 02:15 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: 0DATE:
03/22/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:NATIME COMPLETED:
12:15 PM
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On 03/22/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced collateral visit in order to deliver exclusion letter to staff person (S1) at his/her residence which is not at the facility.

LPA hand delivered the exclusion letter addressed to S1 at his/her home address. LPA provided the letter in a sealed envelope and included LPAs business card a well as part of the letter. LPA taped the letter to the door that matched the address of S1. LPA took photos of the letter taped to the door which also displays home address number. LPA forwarded photos to management as proof of delivery to the address.

LPA did not meet anyone during this visit.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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