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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415601129
Report Date:
11/27/2023
Date Signed:
11/27/2023 03:11:03 PM
Document Has Been Signed on
11/27/2023 03:11 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
SAN BRUNO RO
,
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:
(650) 477-2857
CITY:
MONTARA
STATE:
CA
ZIP CODE:
94037
CAPACITY:
24
CENSUS:
18
DATE:
11/27/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:30 PM
MET WITH:
Eloisa Bustamante
TIME COMPLETED:
03:30 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit to amend LIC9099 and LIC9099A reports dated from 11/21/2023. LPA met with administrator Eloisa Bustamante and explained the purpose of today's visit.
LPA discussed the amendments made and reviewed the amended documents with her.
No new citations issued.
Report is reviewed with Eloisa.
SUPERVISOR'S NAME:
April Cowan
TELEPHONE:
(650) 266-8865
LICENSING EVALUATOR NAME:
Jaime Vado
TELEPHONE:
(559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE:
11/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/27/2023
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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