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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600999
Report Date: 01/26/2024
Date Signed: 01/26/2024 12:16:50 PM


Document Has Been Signed on 01/26/2024 12:16 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: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:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Russlyn Guevarra and Fatollah GhlichlooTIME COMPLETED:
12:30 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 4 client bedrooms and 2 full bathrooms. This facility serves developmentally disabled persons. Clothes washer and dryer are located in attached 2 car garage. There is a detached storage shed in back yard where diapers, PPE and supplies are stored. No accessible bodies of water or fire safety hazards observed. Food supplies are adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. An updated Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including current first aid training and health screenings. Fatollah Ghlichloo is a certified RCFE administrator (x 6/24) that oversees facility operations.

The following information/forms are provided to LPA today:

- Proof of current surety bond
- Proof of current liability insurance


No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.
See Technical Violations issued--3 pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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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