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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601169
Report Date: 06/19/2024
Date Signed: 06/19/2024 01:19:59 PM

Document Has Been Signed on 06/19/2024 01:19 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:REGISTRY OF NURSES-ADULT ASSISTED LIVING FACILITYFACILITY NUMBER:
415601169
ADMINISTRATOR/
DIRECTOR:		YAMAT, FRANCIS HFACILITY TYPE:
735
ADDRESS:32 LARKSPUR AVENUETELEPHONE:
(415) 533-0943
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 0DATE:
06/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:No oneTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On June 19, 2024, at 1:00 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 1:00 PM to deliver an amended report. LPA Calandra range the doorbell two times and knocked on the door two times but no one came to the door. LPA Calandra then contacted the Applicant via phone and left him a voicemail then texted him.

This visit will be conducted again on a later date.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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