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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708114
Report Date: 07/24/2024
Date Signed: 07/24/2024 04:20:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/24/2024 04:20 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:VILLA SIENAFACILITY NUMBER:
430708114
ADMINISTRATOR:BERNARD,CORINEFACILITY TYPE:
740
ADDRESS:1855 MIRAMONTE AVENUETELEPHONE:
(650) 961-6484
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY:77CENSUS: 68DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Corine BernardTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Corine Bernard.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the facility kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed emergency supplies and PPE supplies in a storage area.

LPA toured 5 resident living units and observed each living unit to have available bedding and clothing storage areas as well as bathrooms with shower chairs and anti-slip mats. The water temperature in the bathrooms was 119 F. LPA toured the outside area and observed the exits to be clear of obstructions.

LPA reviewed 5 resident records and Centrally Stored Medication and Destruction Records and found them to be complete. LPA reviewed 5 staff records and found them to be complete.

Facility records indicate that the last smoke detector system test was conducted on 03/01/2024 and the last emergency disaster drill was conducted on 05/07/2024.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Corine Bernard and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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