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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210045
Report Date: 05/29/2024
Date Signed: 05/29/2024 06:14:19 PM

Document Has Been Signed on 05/29/2024 06:14 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LOLA'S HOMEFACILITY NUMBER:
419210045
ADMINISTRATOR/
DIRECTOR:		ADAM CANONFACILITY TYPE:
735
ADDRESS:2956 FLEETWOOD DRIVETELEPHONE:
(650) 873-3530
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
05/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:30 PM
MET WITH:Manager, Joyce CangcangTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
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On May 29, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to deliver an immediate exclusion letter regarding a staff member. Upon entry, LPA met with caregiver, Brenda Parco and LPA explained the purpose of the day. The manager arrived shortly thereafter.

During today's visit, LPA delivered an immediate exclusion letter to exclude a staff member. The manager confirmed that the staff member in the letter is no longer working at the facility. LPA informed the manager that the staff member is no longer allowed to enter the facility or have any contacts with clients in care.

No deficiency cited today.

This report is reviewed and discussed with the manager . A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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