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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708050
Report Date: 12/22/2020
Date Signed: 12/22/2020 10:28:24 AM

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:TERRACES AT LOS ALTOS, THEFACILITY NUMBER:
430708050
ADMINISTRATOR:GONZALES, DEBORAHFACILITY TYPE:
741
ADDRESS:373 PINE LANETELEPHONE:
(650) 948-8291
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY:250CENSUS: 142DATE:
12/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Debby GonzalesTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) David Marrufo and HFEN Nurse Sheryll Falcone conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA Marrufo and HFEN Nurse Sheryll Falcone met with Administrator Debby Gonzales and Valerie Alves.

The Administrator reports that there are currently 6 COVID-19 positive residents and 3 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by HFEN Sheryll Falcone:

1. Advise staff to wear gloves when handling PPEs
2. Place PPEs, including gowns, in plastic container in front of isolation rooms
3. Keep chairs in common areas six feet apart

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

This report was reviewed with Valerie Alves. A copy of the report will be sent to her for it to be signed and returned to CCL.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2020
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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