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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601052
Report Date: 03/18/2024
Date Signed: 03/18/2024 03:09:47 PM


Document Has Been Signed on 03/18/2024 03:09 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SILVER OAKSFACILITY NUMBER:
415601052
ADMINISTRATOR:OLLIE VANCEFACILITY TYPE:
740
ADDRESS:16 COLEMAN PLACETELEPHONE:
(650) 322-2022
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:43CENSUS: 36DATE:
03/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Ollie Vance & Shayla BrewsterTIME COMPLETED:
03:25 PM
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On 3/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Administrator, Ollie Vance and Resident Care Coordinator Shayla Brewster and explained the purpose of the visit.

On 2/12/24 an incident report was submitted to Licensing regarding a resident choking.

LPA Donato collected pertinent documents for review.

No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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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