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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601156
Report Date: 10/04/2023
Date Signed: 10/04/2023 10:30:18 AM

Document Has Been Signed on 10/04/2023 10:30 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:CEDARHILL MANOR IIFACILITY NUMBER:
415601156
ADMINISTRATOR:CAYABYAB, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:1117 EL CAMINO REAL, #1TELEPHONE:
(650) 242-5740
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 4CENSUS: 0DATE:
10/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator/Licensee, Janice CayabyabTIME COMPLETED:
10:30 AM
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On October 4, 2023 Licensing Program Analysts (LPA), Murial Han and John Calandra conducted a case management visit to complete the post-licensing inspection.

When LPAs arrived at the facility, there was no one answer the door bell, therefore, LPAs rang the door bell of Cedarhill Manor which was located next door and caregiver Arlene Olivar answered the door and LPAs explained the purpose of the visit. Caregiver stated that there was no residents at the other facility and the administrators were not present.

Caregiver proceeded with opening the door to Cedarhill Manor II and also got in contact with the administrator on the phone.

LPAs toured the facility and did not observe any residents and spoke with administrator and explained the purpose of the visit. Administrator stated that facility was recently vendorized by GGRC and is now ready to start admitting residents. LPAs reminded administrator to notify CCL when 1st resident is admitted for CCL to proceed with the post-licensing inspection.

This report is reviewed and discussed with administrator over the phone.

A copy will be provided to administrator via email who will sign and send it back to LPAs by the end of the day, 10/4/2023.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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