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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600999
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:56:02 PM


Document Has Been Signed on 07/20/2022 12:56 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ROBERTA CARE HOMEFACILITY NUMBER:
415600999
ADMINISTRATOR:GHLICHLOO, FATOLLAHFACILITY TYPE:
740
ADDRESS:1647 ROBERTA DRIVETELEPHONE:
(650) 389-7603
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:4CENSUS: 4DATE:
07/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Joseph EstepaTIME COMPLETED:
01:05 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management investigation visit to deliver the exclusion letter regarding a staff person (S1). LPA met with caregiver Joseph and explained purpose of today's visit.

LPA met with Joseph in private and explained purpose of the letter being delivered today. He confirmed that S1 has not worked in the facility for approximately two to three years. Joseph has worked in this facility for about 1.5 years and S1 has not worked in this facility since he's been employed here. He informed LPA that S1 did visit the outside of the facility around July 4, 2022 to deliver meat to the facility but did not enter the facility. LPA made observations of the facility's two restrooms with Joseph. There were no suspicious observations made.

Report is reviewed with Joseph. Letter is hand delivered to Joseph on this day.

No citations issued.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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