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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415601079
Report Date:
08/26/2022
Date Signed:
08/26/2022 10:57:05 AM
Document Has Been Signed on
08/26/2022 10:57 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
SF COASTAL AC/SC
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
OLIVIA'S CARE HOME III
FACILITY NUMBER:
415601079
ADMINISTRATOR:
DE GUZMAN, PATRICIA
FACILITY TYPE:
740
ADDRESS:
317 W 20TH AVENUE
TELEPHONE:
(650) 638-0352
CITY:
SAN MATEO
STATE:
CA
ZIP CODE:
94403
CAPACITY:
6
CENSUS:
6
DATE:
08/26/2022
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Annalissa Condez
TIME COMPLETED:
11:00 AM
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On this day Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra conducted an unannounced collateral investigation visit in conjunction to a complaint received under previous licensee. LPAs met with Annalissa Condez and explained the purpose of today's visit.
LPAs explained that the visit was triggered due to a complaint being received under the previous licensed facility Rosie's Home For The Aged who used to run at this facility's current address. These allegation and investigation does not pertain to the current licensee at this time.
Report is reviewed with Annalissa. No citations issued.
SUPERVISORS NAME
:
Jackie Jin
LICENSING EVALUATOR NAME
:
Jaime Vado
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/26/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/26/2022
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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