<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708114
Report Date: 12/22/2020
Date Signed: 12/22/2020 03:23:46 PM

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:VILLA SIENAFACILITY NUMBER:
430708114
ADMINISTRATOR:BERNARD,CORINEFACILITY TYPE:
740
ADDRESS:1855 MIRAMONTE AVENUETELEPHONE:
(650) 961-6484
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY:77CENSUS: 64DATE:
12/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Corine BernardTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Marrufo and HFEN Nurse Helen Widegren 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 Helen Widegren met with Administrator Corine Bernard and Ann Kaye.

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

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

1. Continue implementing prevention and mitigation plan

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

This report was reviewed with Administrator Corine Bernard. 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)
Page: 1 of 1