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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708114
Report Date: 07/16/2021
Date Signed: 07/16/2021 01:55:50 PM

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:VILLA SIENAFACILITY NUMBER:
430708114
ADMINISTRATOR:BERNARD,CORINEFACILITY TYPE:
740
ADDRESS:1855 MIRAMONTE AVENUETELEPHONE:
(650) 961-6484
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY:77CENSUS: 70DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Corine BernardTIME COMPLETED:
02:10 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 conducted an unannounced Required - 1 Year visit and met with Corine Bernard.

During visit, LPA Marrufo toured the facility. LPA Marrufo observed there to be a visitor screening area in the facility entrance. LPA Marrufo toured four resident living units and found the residents had adequate supplies of soap and paper towels in the bathrooms. LPA Marrufo toured the facility medicine rooms on the top and second floors and the facility storage room in the basement floor and observed there to be a PPE supply of at least 30 days. LPA Marrufo observed the facility staff break rooms and dinning rooms.

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

LPA Marrufo requests that the following documents be updated and copies sent to CCLD:

LIC500 Personnel Report
LIC308 Designation of Administrative Responsibility
LIC610 Emergency Disaster Plan

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

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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