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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601127
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:12:14 PM


Document Has Been Signed on 04/09/2024 03:12 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: 61DATE:
04/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Shayan Gheisar, Executive DirectorTIME COMPLETED:
03:30 PM
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On April 9, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 3:00 pm to conduct an unannounced Case Management visit to investigate a death that occurred in January 2024. LPA Calandra was greeted by Shayan Gheisar, Executive Director and explained the purpose of his visit.

LPA Calandra requested the following documents:

-Assisted Living Schedule
-Training records

LPA Calandra interviewed 1 staff member.

No deficiencies were cited during today's visit.

This report was reviewed with Executive Director, Shayan Gheisar, 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: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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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