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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601121
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:46:16 PM

Document Has Been Signed on 11/02/2021 01:46 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:CEDARHILL MANORFACILITY NUMBER:
415601121
ADMINISTRATOR:FORONDA-CAYABYAB, MARIE JAFACILITY TYPE:
735
ADDRESS:1117 EL CAMINO REAL #2TELEPHONE:
(510) 915-0629
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 4CENSUS: 0DATE:
11/02/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cayabyab, Christopher, Foronda-Cayabyab, Marie JanTIME COMPLETED:
01:30 PM
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Facility Type: ARF
Application Type: Intial

COMP II Participants: Foronda-Cayabyab, Marie Jan, Administrator, Cayabyab, Christopher, Corporate Board Member
Interview Method: Telephone interview
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Katie Keith
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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