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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600966
Report Date: 02/03/2022
Date Signed: 02/03/2022 02:58:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GEORGE ANNE HOMEFACILITY NUMBER:
415600966
ADMINISTRATOR:JOHNSON, MARIA LUFACILITY TYPE:
740
ADDRESS:849 N DELAWARE STREETTELEPHONE:
(650) 931-4741
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 5DATE:
02/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lina GuimarinTIME COMPLETED:
03:00 PM
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During complaint investigation visit, LPA Jeung observed that former office has been designated as a private client room. In addition, the garage has been renovated and now accommodates staff in a 1 bedroom apartment, with a bathroom and kitchen. LPA observed 2 bunk beds in the main living area. In the backyard, there are 2 detached storage sheds, both of which are unsecured. Yard sketch was submitted to CCLD in 2020 showing this.

Upon reviewing a client's file, some observations are made.

See Advisiory Note for recommendations.

The following forms/information are requested to be submitted to CCLD by 2/10/22:
- Facility Sketch -- showing designation of rooms
- Personnel Report (LIC500)
- Designation of Administrative Responsibility (LIC308 signed by licensee designating administrator)

No deficiencies cited.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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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