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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600796
Report Date:
07/01/2024
Date Signed:
07/01/2024 05:41:35 PM
Document Has Been Signed on
07/01/2024 05:41 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
CAPAY HOME
FACILITY NUMBER:
415600796
ADMINISTRATOR/
DIRECTOR:
ALYSSA JOY DECANO
FACILITY TYPE:
740
ADDRESS:
22 CAPAY CIRCLE
TELEPHONE:
(510) 305-8919
CITY:
SOUTH SAN FRANCISCO
STATE:
CA
ZIP CODE:
94080
CAPACITY:
4
CENSUS:
4
DATE:
07/01/2024
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
05:37 PM
MET WITH:
Alyssa Joy Decano
TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Continuation to complete the inspection tool.
SUPERVISORS NAME
:
Andrea Medlin
LICENSING EVALUATOR NAME
:
Grace Donato
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/01/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2024
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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