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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 06:04:44 PM

Document Has Been Signed on 06/05/2024 06:04 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/
DIRECTOR:		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 VISIT/
INSPECTION BEGAN:
05:50 PM
MET WITH:House Manager - Ryan BelongTIME VISIT/
INSPECTION COMPLETED:
06:10 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 Ryan Belong 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 Ryan. At 10pm to 6am only 2 staff are on duty overnight. LPA made observations around the facility. LPA observed all 4 residents in their rooms in bed. 2 residents go to a day program and returned around 3pm per Ryan. The other 2 residents do in home day programs. 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.

LPA is requesting LIC209 administrative organization and control of property.

Report is reviewed with Ryan. Copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
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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