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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601000
Report Date: 01/09/2024
Date Signed: 01/09/2024 05:19:12 PM


Document Has Been Signed on 01/09/2024 05:19 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:SOLEDAD'S HOMEFACILITY NUMBER:
415601000
ADMINISTRATOR:BELONG, RACHELFACILITY TYPE:
740
ADDRESS:2880 BERKSHIRE DRIVETELEPHONE:
(650) 454-9905
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:4CENSUS: 3DATE:
01/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rachel BelongTIME COMPLETED:
01:55 PM
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On 1/9/24 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit. LPA met with Admininstrator Rachel Belong. LPA explained the purpose of today's visit.

LPA delivered an immediate exclusion letter to exclude a staff who worked in the facility before. Staff has not been working in the facility since February 12, 2023.

The letter was given to and reviewed by the Administrator.

This report is reviewed and discussed, and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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