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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601147
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:32:55 PM

Document Has Been Signed on 12/09/2022 01:32 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:WALLY'S PLACE, MATEO LODGE, INC.FACILITY NUMBER:
415601147
ADMINISTRATOR:SANDOVAL, MARYFACILITY TYPE:
735
ADDRESS:695 FIFTH AVE.TELEPHONE:
(650) 568-9008
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 13CENSUS: 0DATE:
12/09/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Kris Eryk Bartolome, Director/ Administrator
Mary Sandoval, Administrator
Ian Adamson, Corporate Membe
r		TIME COMPLETED:
01:25 PM
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Component II completion: Successful

Facility Type: Adult Residential Facility (AFR)
Application Type: Change of Facility Type (CHOFT)
Capacity: 13
Census (if any clients in care): none
COMP II Participants:
Kris Eryk Bartolome, Director/Administrator
Mary Sandoval, Administrator
Ian Adamson, Corporate Member
Interview Method: Telephone interview

On December 9, 2022 , Applicant and Administrators participated in COMP II. Identification of the Applicant and Administrators was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrators 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.

During COMP II, CAB analyst confirmed Applicant and 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

Exit interview conducted with Applicant and Administrator. Report sent via email PDF and informed to return signed copy by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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