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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210071
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:05:22 PM

Document Has Been Signed on 07/20/2022 12:05 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
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:
07/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator and LicenseeTIME COMPLETED:
12:10 PM
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On 7/20/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit and met with the Administrator, Russlyn Guevarra and Licensee, Fatollah Ghlichloo.

The purpose of today's visit is to deliver an immediate exclusion letter to exclude an employee of the facility.

The letter was given and reviewed by the administrator and licensee.

This report is reviewed and discussed with administrator and licensee. A copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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