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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708050
Report Date: 06/07/2021
Date Signed: 06/07/2021 10:47:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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: 160DATE:
06/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Valerie AlvesTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced COVID-19 Infection Control Required 1 Year Visit and met with Valerie Alves.

During visit, LPA Marrufo toured facility entrance areas, bathrooms, common dinning areas, and PPE supply areas. The facility has a single facility entrance with COVID-19 screening. Staff members were observed to be wearing masks. Restrooms were observed to have an adequate supply of soap and paper towels. Facility staff break room areas were observed to provide space for social distancing.

Facility observed to have an adequate supply of PPEs.


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

This report was reviewed with Valerie Alves and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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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