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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601168
Report Date: 03/20/2024
Date Signed: 03/20/2024 09:47:11 AM

Document Has Been Signed on 03/20/2024 09:47 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:WELCOME HOMEFACILITY NUMBER:
415601168
ADMINISTRATOR:YEMA, HERMIEFACILITY TYPE:
735
ADDRESS:117 ARROYO DRTELEPHONE:
(650) 757-7725
CITY:S SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 7CENSUS: 0DATE:
03/20/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:16 AM
MET WITH:Hermie YermaTIME COMPLETED:
10:00 AM
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On 3/20/2024, Licensing Program Analyst (LPA) Grace Donato conducted an announced Pre-Licensing Inspection visit. LPA met with Administrator Hermie Yerma.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed the indoor and the outdoor passageways are free of obstruction. Facility is single level with 7 bedrooms and 3 full baths. All rooms are observed with required furniture and lighting, Bathrooms to be odor-free and in good repair.

Facility lighting is sufficient for comfort and safety. LPA toured the kitchen area and observed it to be clean. Facility refrigerator temperatures are within regulatory standards. Chemicals & sharps have their own locked storage. All fire prevention systems such as smoke detectors, carbon monoxide detectors, fire extinguishers have been inspected in place.

Component III is also conducted on this day.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued.

A copy of report is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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