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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210072
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:03:31 AM

Document Has Been Signed on 11/10/2022 10:03 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OLYMPIC HOMEFACILITY NUMBER:
419210072
ADMINISTRATOR:ANTOLIN G. UCOLFACILITY TYPE:
735
ADDRESS:2415 OLYMPIC DRIVETELEPHONE:
(650) 873-3998
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 5DATE:
11/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Caregiver, Michael PonceTIME COMPLETED:
10:15 AM
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On November 10, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident reported to CCLD on November 7, 2022. LPA met with Caregiver, Michael Ponce and explained the purpose of the visit.

During the visit, LPA toured the facility and received pertinent documents in relation to the incident. LPA requested additional documents to be emailed by the end of the day.

No citations are issued during the visit. LPA reviewed report with Caregiver, Michael Ponce and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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