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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601129
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:36:55 AM


Document Has Been Signed on 11/01/2022 11:36 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:JLA HEALTHCARE SERVICES LLCFACILITY NUMBER:
415601129
ADMINISTRATOR:LEONARD, JEROMEFACILITY TYPE:
740
ADDRESS:1185 ACACIA STREETTELEPHONE:
(510) 313-3673
CITY:MONTARASTATE: CAZIP CODE:
94037
CAPACITY:24CENSUS: 12DATE:
11/01/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Eloisa BustamanteTIME COMPLETED:
11:45 AM
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On November 1, 2022, Licensing Program Analyst (LPA) Komal Charitra complaint collateral visit to deliver findings deliver findings to a complaint received under Licensee's previous address. LPA met with Administrator, Eloisa Bustamante and explained the purpose of the visit.

LPA Charitra delivered findings regarding a complaint made at Licensees previous facility #415601068 which is now closed and moved to this location.

Report is reviewed with Administrator and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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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