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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210106
Report Date: 03/10/2023
Date Signed: 03/10/2023 04:26:18 PM

Document Has Been Signed on 03/10/2023 04:26 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FENIX HOMEFACILITY NUMBER:
419210106
ADMINISTRATOR:LILIBETH LETRONDOFACILITY TYPE:
735
ADDRESS:437 FERNDALE AVETELEPHONE:
(650) 580-1266
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 4DATE:
03/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Welisa Dumlao TolentinaTIME COMPLETED:
04:30 PM
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
LPA Jeung met with staff and provided letters of immediate exclusion for 2 staff to assistant administrator Welisa Tolentina. Letters of immediate exclusion addressed to Gratia Home are also delivered for the same 2 staff, as this home and Gratia Home are managed by administrator Lilibeth Letrondo. According to administrator Lilibeth Letrondo, the 2 staff have not yet started working at her facilities. LPA observed 4 clients in the living room with 4 staff. REsidents occupy private rooms. Male client admitted yesterday resides in rear room located on the same side of building as kitchen, which has a direct exit to outside.

No deficiency cited today.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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