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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601127
Report Date: 03/19/2024
Date Signed: 03/19/2024 04:01:55 PM


Document Has Been Signed on 03/19/2024 04:01 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:SERRA HIGHLANDS SENIOR LIVINGFACILITY NUMBER:
415601127
ADMINISTRATOR:SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:501 KING DRIVETELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:120CENSUS: 60DATE:
03/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Shayan Gheisar, Executive Director TIME COMPLETED:
04:15 PM
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On March 19, 2024 at 1:21 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management in regards to a death that occurred on January 20, 2024. LPA Calandra met with Shayan Gheisar, Executive Director and explained the purpose of his visit.

LPA Calandra asked for the following documents:

1. Resident and Medical file for R1
2. Staff schedule for January 2024
3. Staff training
4. 6 Staff files

LPA Calandra reviewed 6 staff files and staff training records.

LPA Calandra also interviewed 2 staff members.

No deficiencies were cited during today's visit. This report was reviewed with Shayan Gheisar, Executive Director and a copy of the report left at the facility.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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