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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600833
Report Date:
06/30/2023
Date Signed:
06/30/2023 02:15:33 PM
Document Has Been Signed on
06/30/2023 02:15 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:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
ADMINISTRATOR:
DEBORAH M. DAHLEN
FACILITY TYPE:
740
ADDRESS:
2585 ARDEE LANE
TELEPHONE:
(650) 873-8635
CITY:
SOUTH SAN FRANCISCO
STATE:
CA
ZIP CODE:
94080
CAPACITY:
6
CENSUS:
3
DATE:
06/30/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:10 PM
MET WITH:
Deborah Dahlen
TIME COMPLETED:
02:30 PM
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LPA Grace Donato made an unannounced case management in the facility. LPA met with Licensee Deborah Dahlen. LPA explained the purpose of the visit.
This case management visit is with regards to following up about staff personnel files in the facility. LPA is here to check if staff files are all organized and that first aid training are up to date.
3 personnel files were reviewed. 2 out of 2 are all up to date and trainings are complete. One staff member hasn't had training as of the moment due to being out of the country.
No citations given for todays visit. A copy if this report is provided.
SUPERVISORS NAME
:
Jackie Jin
LICENSING EVALUATOR NAME
:
Grace Donato
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
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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