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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210053
Report Date: 08/30/2024
Date Signed: 08/30/2024 04:13:56 PM

Document Has Been Signed on 08/30/2024 04:13 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:CHANZE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
419210053
ADMINISTRATOR/
DIRECTOR:		MARIMIL, SANTOSFACILITY TYPE:
735
ADDRESS:1112 SUNNYSIDE DRIVETELEPHONE:
(650) 291-5330
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 3CENSUS: 3DATE:
08/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:House Manager Ramon De Los Santos and Marieann OrtizTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 08/30/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to deliver an exclusion letter regarding a staff person. LPA explained the purpose of today's visit with the house manager Ramon De Los Santos and lead staff Marieann. LPA spoke to Ramon via telephone on speaker phone and discussed with him the purpose of today's visit and the contents of the letter.


LPA provided the letter to the lead staff Marieann and discussed the reason of the letter. Per Ramon the staff person has not been working at the facility for maybe seven years as he doesn't recall the name of the staff person. He says that there is no staff person on roster at this time that works at the facility under that name. He also confirmed that he is the house manager for the sister facility Lexy's Adult Residential Facility #415610006. He accepted this letter at the sister facility Lexy's indicating he is the the house manager for both locations and he knows the licensee for both facilities.

Ramon understands the purpose of the letter and will follow its instructions.

Report is reviewed with Ramon and Maryanne and a copy is provided on this day.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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