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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601122
Report Date: 06/30/2023
Date Signed: 06/30/2023 01:58:05 PM

Document Has Been Signed on 06/30/2023 01:58 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:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALEJANDRO, VICTORIAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 3CENSUS: 3DATE:
06/30/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Veronica RozarioTIME COMPLETED:
02:15 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted a collateral visit at this facility in order to deliver findings for another facility, Cypress Home #415601119 due to Cypress being in a fire an inaccessible at this time. LPA Vado discussed with the administrator of Cypress Virctoria Alejandro the allegation findings via telephone. LPA met with facility manager Veroncia Rozario and explained the purpose of today's visit.

LPA Vado discussed and delivered findings to Veroniza Rozario on this day.

No citation issued.

Report discussed with Veronica.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
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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