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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701864
Report Date: 10/29/2021
Date Signed: 10/29/2021 02:47:23 PM

Document Has Been Signed on 10/29/2021 02:47 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LYTTON GARDENS COMMUNITY CAREFACILITY NUMBER:
430701864
ADMINISTRATOR:DORIS LEEFACILITY TYPE:
740
ADDRESS:649 UNIVERSITY AVENUETELEPHONE:
(650) 617-7338
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY: 55CENSUS: 39DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Doris LeeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted a Required - 1 Year visit and met with Doris Lee and Anahi McKane.

During visit, LPA Marrufo observed the visitor screening area. LPA observed the hallway bathroom near the entrance and observed there to be COVID-19 related posters and available soap and paper towels. LPA Marrufo observed more COVID-19 related posters throughout the facility. LPA observed the facility PPE storage and observed there to be a PPE supply of at least 30 days. LPA observed the kitchen area and observed there to be a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA observed the dinning area and two resident common areas.

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

This report was reviewed with Doris Lee and Anahi McKane and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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