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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803718
Report Date: 09/22/2021
Date Signed: 09/22/2021 01:44:21 PM

Document Has Been Signed on 09/22/2021 01:44 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:EDRINE HOMEFACILITY NUMBER:
486803718
ADMINISTRATOR:BALAURO, NESTORFACILITY TYPE:
735
ADDRESS:503 VIA VAQUEROTELEPHONE:
(650) 703-1217
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 4DATE:
09/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Irene Monteclar, LicenseeTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Irene Monteclar, Licensee. The purpose of this case management inspections were to follow up on self reported incident report submitted to Community Care Licensing (CCL).

On 9/18/21, R1 was sent to hospital due to swollen legs. During visit LPA Lopez requested documents and took statements from Licensee.


No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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