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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601062
Report Date: 05/21/2024
Date Signed: 05/21/2024 08:50:38 AM

Document Has Been Signed on 05/21/2024 08:50 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:HOME SWEET HOME RESIDENTIAL CARE CORPORATIONFACILITY NUMBER:
415601062
ADMINISTRATOR/
DIRECTOR:		SANTIAGO, LUZFACILITY TYPE:
735
ADDRESS:3722 BRANSON DRTELEPHONE:
(650) 522-8184
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
05/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Licensee - Luz Santiago/Caregiver - Renato PasaoaTIME VISIT/
INSPECTION COMPLETED:
09:00 AM
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On 05/21/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to deliver letter of immediate exclusion regarding a staff member associated with this facility. LPA met with caregiver in person but at approximately 0835am LPA talked with the licensee via telephone.

LPA provided the letter of exclusion to the caregiver and informed him what the letter is for regarding the staff member. LPA was informed that the staff person in the letter is a current staff member. LPA informed the licensee that the staff member is no longer allowed to work at the facility and must be disassociated at this time. LPA explained this to the licensee via telephone and LPA informed staff on site in the facility that the staff member in the letter is no longer allowed to enter the facility or have contact with clients in care.

No citations issued.

Report reviewed with licensee and caregiver.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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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