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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415610006
Report Date: 01/29/2025
Date Signed: 01/29/2025 03:30:57 PM

Document Has Been Signed on 01/29/2025 03:30 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:LEXY'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
415610006
ADMINISTRATOR/
DIRECTOR:		MARIMIL S. SANTOS DE LOSFACILITY TYPE:
735
ADDRESS:108 GREENWOOD DRIVETELEPHONE:
(650) 291-5328
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 3DATE:
01/29/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:33 PM
MET WITH:Marie Ann OrtizTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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On 1/29/2025 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit. LPA met with Direct Support Staff (DSP) Marie Ann Ortiz. LPA explained the purpose of today's visit.

LPA delivered an immediate exclusion letter to exclude a staff (S1) who worked in the facility before. Staff has not worked at the facility since 2017. Staff was advised that S1 is not allowed to work in the facility.

The letter was given to and reviewed by the DSP.

This report is reviewed and discussed, and a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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