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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601000
Report Date: 06/05/2024
Date Signed: 06/05/2024 04:36:24 PM


Document Has Been Signed on 06/05/2024 04:36 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: 4DATE:
06/05/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Home manger - Rem PauleTIME COMPLETED:
04:35 PM
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On 06/05/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - health check. LPA met with home manger Rem Paule and explained the purpose of today's visit.

There are currently 4 staff on duty and 4 residents present. This facility provides 1:1 care per Rem. LPA made observations around the facility. LPA observed 2 residents in the living room adjacent to kitchen sitting in chairs. 2 other residents were observed in their rooms. One resident was in bed. All residents go to a day program and returned around 3pm per Rem. Dinner is being cooked. LPA did not see any concerning items to note regarding the residents in care's health and safety or staff on duty. Residents did not appear to be in distress. Residents were walking around, interacting with staff and LPA, and responsive when spoken to.

Report is reviewed with Rem. Copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024
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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