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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415601054
Report Date:
08/04/2022
Date Signed:
08/04/2022 05:37:47 PM
Document Has Been Signed on
08/04/2022 05:37 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:
OLIVIA'S CARE HOME II
FACILITY NUMBER:
415601054
ADMINISTRATOR:
GUZMAN, OLIVIA DE
FACILITY TYPE:
740
ADDRESS:
48 WEST 39TH AVE
TELEPHONE:
(415) 609-4688
CITY:
SAN MATEO
STATE:
CA
ZIP CODE:
94403
CAPACITY:
6
CENSUS:
6
DATE:
08/04/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
05:00 PM
MET WITH:
Kate Pasaymau and Olivia De Guzman
TIME COMPLETED:
05:01 PM
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In order to amend Facility Evaluation Report of 7/25/22, LPA Jeung issued corrected deficiency page--LIC809D. Corrected copy is signed and given to administrator.
SUPERVISOR'S NAME:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
08/04/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/04/2022
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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