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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210071
Report Date: 07/18/2022
Date Signed: 07/18/2022 09:29:08 AM

Document Has Been Signed on 07/18/2022 09:29 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NORCAL CARE HOMES, INC.FACILITY NUMBER:
419210071
ADMINISTRATOR:RUSSLYN OLGA A GUEVARRAFACILITY TYPE:
735
ADDRESS:460 BODEGA STREETTELEPHONE:
(650) 377-2530
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 3CENSUS: 3DATE:
07/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Licensee, Fatollah GhlichlooTIME COMPLETED:
09:40 AM
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On July 18, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident reported to CCLD on July 15, 2022. LPA met with Administrator, Russlyn Guevarra, and Licensee, Fatollah Ghlichloo joined shortly thereafter. LPA Charitra explained the purpose of the visit.

During the visit, LPA toured the facility and interviewed staff regarding the incident. LPA received pertinent documents in relation to the incident.

No citations issued during this visit.

Report is reviewed with Licensee and a copy is provided.

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
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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