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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600868
Report Date: 04/04/2023
Date Signed: 04/04/2023 03:10:05 PM


Document Has Been Signed on 04/04/2023 03:10 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:PALM ASSISTED LIVING LLCFACILITY NUMBER:
415600868
ADMINISTRATOR:RENUKA GANDHIFACILITY TYPE:
740
ADDRESS:2818 TIBURON WAYTELEPHONE:
(650) 651-7031
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:6CENSUS: 0DATE:
04/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Renuka GandhiTIME COMPLETED:
03:15 PM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - closure visit. LPA met with licensee Renuka Gandhi and explained the purpose of todays visit.

LPA Vado met the licensee at the door of the facility. LPA toured the facility with the licensee. Most of the furniture is moved out of the facility. Resident bedrooms are empty with no furniture or resident belongings. There is no living room furniture present. This facility is vacant. According to the licensee the last resident moved out on January 9, 2023 on their accord. The facility did have a COVID incident with one resident. Residents then moved out on their own according to the licensee. One resident was already at a family members house and never returned due to the COVID incident.

The facility is closed and has not had any residents since January 9, 2023.

Report is reviewed with the licensee and a copy of this report is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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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