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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601105
Report Date: 05/10/2022
Date Signed: 05/10/2022 01:29:45 PM


Document Has Been Signed on 05/10/2022 01:29 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:FAMILY AFFAIR CARE HOMEFACILITY NUMBER:
415601105
ADMINISTRATOR:LESLIE, HUI C.FACILITY TYPE:
740
ADDRESS:3100 COLLEGE DR.TELEPHONE:
(650) 871-5095
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 3DATE:
05/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lead Caregiver, Ganalyn (Gina) DavidTIME COMPLETED:
01:40 PM
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On 5/10/2022, Licensing Program Analyst, (LPA) Murial Han conducted an unannounced case management visit on behalf of LPA, Audrey Jeung regarding facility's request of increasing total capacity from 6 to 10.

LPA was greeted by lead caregiver, Gina David who called administrator, Leslie (Carol) Hui informing of LPA's visit. LPA explained the purpose of the visit to lead caregiver and administrator.

During today's visit, lead caregiver provided a facility tour, LPA observed construction workers on site, LPA reviewed and compared the old and the new facility sketch and requested for the following documents to be submitted to LPA Jeung by 5/12/22:

- A copy of the Conditional Use Permit
- Name and contact information of the fire inspector
- Proof of notification to residents, responsible party(s) and CCL regarding the project of increasing capacity
- A check of $25 made to Department of Social Services for the change of capacity
- A copy of the approved building permit

This report is reviewed and discussed with administrator via phone and lead caregiver.

A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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