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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708050
Report Date: 11/09/2022
Date Signed: 11/09/2022 04:37:10 PM


Document Has Been Signed on 11/09/2022 04:37 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: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: 174DATE:
11/09/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Deborah GonzalezTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Deborah Gonzalez. The purpose of the Case Management visit was to conduct a health and wellness check on resident R1, who transferred to the facility from another facility.

During visit, LPA Marrufo visited R1 in R1's apartment. LPA Marrufo asked R1 if the facility staff have been providing R1 with meals, assistance with medications, assistance with hygiene and personal care, and assistance with contacting family and loved ones. R1 responded affirmatively to all of the previous questions.

LPA Marrufo toured R1's room and observed there to be bedding, hygiene items, clothing, and available soap and paper towels in the bathroom.

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

This report was reviewed with Administrator Deborah Gonzalez and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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