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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700136
Report Date: 03/07/2024
Date Signed: 03/07/2024 04:07:42 PM


Document Has Been Signed on 03/07/2024 04:07 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:CHANNING HOUSEFACILITY NUMBER:
430700136
ADMINISTRATOR:GONZALEZ-MENDOZ, YADIRA S.FACILITY TYPE:
741
ADDRESS:850 WEBSTER STREETTELEPHONE:
(650) 327-0950
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:264CENSUS: 232DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Yadira Gonzalez-MendozTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Yadira Gonzalez-Mendoz.

During visit, LPA Marrufo toured the food storage areas, including the emergency food supply areas. The facility had a perishable food supply of at least 2 days and a non-perishable food supply of at least seven days. LPA Marrufo observed storage areas for emergency PPE supplies and cleaning supplies.

LPA Marrufo toured the outdoor exits and found them to be clear of obstructions. LPA Marrufo toured resident bedrooms in the Assisted Living Area.

LPA Marrufo reviewed the Centrally Stored Medication Logs of 5 residents and found them to be complete.

LPA Marrufo conducted a resident record review for 5 residents and found them to be complete.

Due to time constraints, the annual inspection will need to be continued at a later time.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Yadira Gonzalez-Mendoz and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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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