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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600729
Report Date: 10/21/2022
Date Signed: 10/21/2022 10:53:53 AM

Document Has Been Signed on 10/21/2022 10:53 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:BEL AMOR IIIFACILITY NUMBER:
415600729
ADMINISTRATOR:DEANDA, OLIVIA & MANNYFACILITY TYPE:
740
ADDRESS:169 SAN FELIPE AVENUETELEPHONE:
(650) 871-7931
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 6DATE:
10/21/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Olivia DeAndaTIME COMPLETED:
11:00 AM
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
On 10/21/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to ensure an excluded individual is no longer employed and has left the premises. LPA met with administrator and explained purpose of today's visit.

During today's visit, LPA toured facility and grounds that was provide by the administrator. This is a single level facility with 6 private rooms, 1 staff room, 2 full bath/shower rooms and 1 half bathroom.

The administrator acknowledged of receiving the exclusion letter for this individual and stated that this individual has not worked at the facility for about 3 years.

LPA interviewed 3 facility staff and 2 of them stated that they have never met and worked with this individual and the 3rd staff stated that this individual has not worked at the facility for several years.

Based on document provided, this individual is no longer working at the facility.

No deficiency cited today.

This report is reviewed and discussed with caregiver, Yolanda Cruz as the administrator has to leave the facility and escort a resident to a medical appointment. However, the outcome of today's visit was discussed with the administrator before the administrator exited the facility.

A copy of this report is provided to the caregiver.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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