<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210065
Report Date: 07/10/2024
Date Signed: 07/10/2024 11:04:42 AM

Document Has Been Signed on 07/10/2024 11:04 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:SABRINA HOMEFACILITY NUMBER:
419210065
ADMINISTRATOR/
DIRECTOR:		JAYSON HERNANDEZFACILITY TYPE:
735
ADDRESS:1219 SABRINA COURTTELEPHONE:
(408) 250-2543
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 3CENSUS: 3DATE:
07/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator - Jayson HernandezTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to deliver letter of immediate exclusion regarding a staff member associated with this facility. LPA met with the administrator Jayson Hernandez and explained the purpose of today's visit.

LPA provided the letter of exclusion to the administrator and informed him what the letter is for regarding the staff member. LPA was informed that the staff person in the letter is a current staff member. LPA informed the administrator that the staff member is no longer allowed to work at the facility and must be disassociated at this time. LPA explained this to the administrator and informed staff on site in the facility that the staff member in the letter is no longer allowed to enter the facility or have contact with clients in care.

Report reviewed with administrator and provided copy of this report and letter with the administrator.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1