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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415601129
Report Date:
10/07/2022
Date Signed:
10/07/2022 01:51:51 PM
Document Has Been Signed on
10/07/2022 01:51 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:
JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER:
415601129
ADMINISTRATOR:
LEONARD, JEROME
FACILITY TYPE:
740
ADDRESS:
1185 ACACIA STREET
TELEPHONE:
(510) 313-3673
CITY:
MONTARA
STATE:
CA
ZIP CODE:
94037
CAPACITY:
24
CENSUS:
DATE:
10/07/2022
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Eloisa Bustamante
TIME COMPLETED:
02:00 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint collateral visit to deliver findings in the above received allegations. LPA met with licensee Eloisa Bustamante and explained purpose of today's visit.
LPA is delivering the findings regarding a complaint made at her previous facility #415601068 which is now closed and moved to this location. LPA discussed and made observations on this day. LPA discussed the report findings with the licensee and provided copies of the findings today.
No citations issued.
Report reviewed with licensee.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Jaime Vado
TELEPHONE:
(559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE:
10/07/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/07/2022
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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