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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601122
Report Date: 12/22/2023
Date Signed: 12/22/2023 11:20:12 AM

Document Has Been Signed on 12/22/2023 11:20 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALPON, NILDAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 3DATE:
12/22/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Nilda AlponTIME COMPLETED:
11:30 AM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced collateral visit in order to deliver documents related to a substantiated complaint allegation; complaint number 14-AS-20230223154313 for Cypress Home #415601119, which is the sister facility of Arbor House. Cypress Home is currently closed with no residents in care. LPA met with administrator Nilda Alpon and explained the purpose of today's visit.

LPA delivered the documents to Nilda Alpon.

No citations issued.

Report is reviewed with Nilda.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2023
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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