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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601127
Report Date: 04/23/2024
Date Signed: 04/23/2024 05:13:53 PM


Document Has Been Signed on 04/23/2024 05:13 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: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:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Shayan GheisarTIME COMPLETED:
01:00 PM
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On April 23, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator and explained the purpose of today's visit.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed the indoor and the outdoor passageways are free of obstruction. This is a two story facility; LPA observed sufficient lighting and comfortable temperature is maintained throughout the facility.

LPA toured the first floor of the facility and observed residents having lunch in the dining room. LPA toured the kitchen located on the first floor and observed 2 day perishable and 7 day non-perishable. Sharps and chemicals were observed to be locked and inaccessible to residents.

LPA observed medications/med cart locked in an office on the 1st floor next to the elevator.

A tour of the rooms were conducted on the 1st and the 2nd floor and observed to be spacious and included all required furnishings. Staff room was observed on first floor to be a break room. Second floor common area and some of the vacant resident rooms are currently undergoing construction.

LPA will return on another day to complete the inspection.

No deficiency cited today.

This report is reviewed and discussed. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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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