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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601122
Report Date: 06/30/2022
Date Signed: 06/30/2022 08:56:28 AM

Document Has Been Signed on 06/30/2022 08:56 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALEJANDRO, VICTORIAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 3DATE:
06/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:House Manager, Homer BautistaTIME COMPLETED:
09:05 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 June 30, 2022, Licensing Program Analysts (LPA) Komal Charitra and Kevin Varilla conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citation that was issued on 6/16/22. LPA Charitra and LPA Varilla met with House Manager, Homer Bautista, and explained the purpose of the visit.

On 6/16/2022, the facility was cited for California Code of Regulation (CCR), 87203 Fire Safety. The plan of correction for this citation was due to CCLD by 6/17/2022. On June 30, 2022, LPAs reviewed and verified the plan of correction documents that were provided by the facility and cleared the citation.

This report is reviewed and discussed with Homer Bautista. A copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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