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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600966
Report Date:
11/21/2023
Date Signed:
11/21/2023 06:02:38 PM
Document Has Been Signed on
11/21/2023 06:02 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
SF COASTAL AC/SC
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
GEORGE ANNE HOME
FACILITY NUMBER:
415600966
ADMINISTRATOR:
JOHNSON, MARIA LU
FACILITY TYPE:
740
ADDRESS:
849 N DELAWARE STREET
TELEPHONE:
(650) 931-4741
CITY:
SAN MATEO
STATE:
CA
ZIP CODE:
94401
CAPACITY:
6
CENSUS:
6
DATE:
11/21/2023
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
02:45 PM
MET WITH:
Maria Johnson
TIME COMPLETED:
06:00 PM
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LPA Jeung reviewed client records to continue annual inspection of 7/17/23.
No deficiencies related to client records are cited today.
SUPERVISORS NAME
:
Cara Smith
LICENSING EVALUATOR NAME
:
Audrey Jeung
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/21/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/21/2023
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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