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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601052
Report Date: 12/14/2021
Date Signed: 12/14/2021 12:38:47 PM

Document Has Been Signed on 12/14/2021 12:38 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SILVER OAKSFACILITY NUMBER:
415601052
ADMINISTRATOR:RUBIO, NANCYFACILITY TYPE:
740
ADDRESS:16 COLEMAN PLACETELEPHONE:
(707) 592-1157
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 43CENSUS: 27DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Nancy RubioTIME COMPLETED:
01:00 PM
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On December 14, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Resident Care Coordinator, Adriana Garcia and the Administrator, Nancy Rubio joined shortly thereafter. LPA Charitra explained the purpose of the visit and LPA was screened at the front entrance. Administrator was able to provide LPA with screening log documentation for residents, staff, and visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, and 30-day PPE supply. Bathrooms are equipped with liquid hand soap, paper towels, and hand-washing signs, however LPA recommends covering trash cans with lids in the bathrooms. COVID-19 signage was observed to be posted through-out the facility such as social distancing, COVID-19 symptoms, face coverings, cough etiquette, etc.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, and a comfortable temperature is maintained, lighting is sufficient for comfort. Dining area was observed to have tables maintaining social distancing.

LPA requests for the following documents to be sent by 12/21/21:
-LIC309 Administrative Organization
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-Administrator Certificate
-LIC610E Emergency Disaster Plan

Report was reviewed with Administrator and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2021
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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