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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601143
Report Date: 12/09/2022
Date Signed: 12/13/2022 12:28:30 PM

Document Has Been Signed on 12/13/2022 12:28 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:DEL MONTE JF INCFACILITY NUMBER:
415601143
ADMINISTRATOR:VERIDIANO, DONNA MARIEFACILITY TYPE:
735
ADDRESS:210 DEL MONTE AVENUETELEPHONE:
(650) 580-2983
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: DATE:
12/09/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Donna VeridianoTIME COMPLETED:
04:00 PM
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Component II completion: Successful

Facility Type: ARF
Application Type: LLC
Capacity: 6
Census (if any clients in care): NO
COMP II Participants: Donna Veridiano (Applicant/Administrator)
Interview Method: Telephone interview


On 12/09/2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

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: Julia Kim
LICENSING EVALUATOR NAME: Thai Doan
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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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