<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601022
Report Date: 08/21/2024
Date Signed: 08/21/2024 11:39:24 AM


Document Has Been Signed on 08/21/2024 11:39 AM - 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:IVY PARK AT BELMONTFACILITY NUMBER:
415601022
ADMINISTRATOR:MILLER, COREYFACILITY TYPE:
740
ADDRESS:1010 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 508-0400
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:117CENSUS: 75DATE:
08/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator - Minnie WeberTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/21/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced pre-licensing inspection visit. LPA met with administrator Minnie Weber and explained the purpose of today's visit.

On this day LPA conducted the pre-licensing inspection for the change in ownership of the facility.

No citations issued.

Report is reviewed with administrator Minnie Weber and a copy is provided on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1