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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200383
Report Date: 12/04/2025
Date Signed: 12/04/2025 03:00:07 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/04/2025 03:00 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:LA SELVAFACILITY NUMBER:
435200383
ADMINISTRATOR/
DIRECTOR:		JIM MILLSAPFACILITY TYPE:
772
ADDRESS:652 FOREST AVENUETELEPHONE:
(650) 323-1401
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY: 12CENSUS: 6DATE:
12/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Quality Improvement - Julia PhillipsTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 12/04/2025, Licensing Program Analyst (LPA) Jaime Vado arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with director of operations, Michelle Ly and explained the purpose of todays visit. She requested LPA to wait for the quality improvement (QI) to arrive to conduct the full tour and inspection with LPA. LPA conducted the tour with QI personnel Julia Phillips. There are currently

This is a multi-level facility with a basement, ground floor, and second floor. The facility is licensed for adults age range of 18 and above and all must be ambulatory. LPA inspected the kitchen and it is found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The sink was empty, and no dirty dishes were observed. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No observable expired food or stored medications were observed in the refrigerator. LPA inspected the fire extinguisher mounted on the wall in the kitchen and found it fully charged, with the last service tag dated 11/24/2025. LPA observed the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. LPA observed playing cards, board games, puzzles, and other recreational activity items for the clients in the dining area. LPA observed a locked closet in the hallway adjacent to the living room, which contained detergents, soap, and cleaning supplies. The facility is observed to be equipped with smoke detectors and carbon monoxide detectors through out the facility.

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NAME OF LICENSING PROGRAM MANAGER: Cara Smith
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: LA SELVA
FACILITY NUMBER: 435200383
VISIT DATE: 12/04/2025
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There are (4) bedrooms and (3) bathrooms designated for client use. All client rooms were shared occupancy. LPA inspected (1) client bedroom on the first floor and (3) client bedrooms on the second floor, and found them clean, well-lit, and equipped with the required furniture. LPA inspected (1) bathroom on the first floor and (2) bathrooms on the second floor, and found them clean, sanitary, and in good working condition. The bathrooms contained soap, paper towels, a trash can, and non-slip mats. The hot water temperature at the sink faucet measured on the second floor at 130F, which poses an immediate health and safety threat to residents in care. LPA inspected the basement and observed (2) washers, (1) dryer, refrigerator containing additional food supplies, and (4) closets containing towels, paper products, laundry soap, cleaning supplies, snacks, cereals, and other dry food products were observed. LPA toured the backyard area and found all passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No accessible bodies of water were found. A shaded area with outdoor patio furniture in good clean condition were observed. Additional facility parking is located in this area as well.

LPA reviewed (3) staff personnel records and (3) client records which were all found to be current. LPA inspected the first aid kit and found it fully stocked. Emergency drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted monthly, with the most recent drill completed on September 2024. LPA observed a locked centrally stored medication cabinet inside the staff office. Medications were organized in separate bins for each client. Centrally Stored Medication and Destruction Records (CSMDR) is reviewed and current

Report is reviewed with Julia Phillips and a copy of this report is provided on this day. Citation is issued on the following LIC809D page.

NAME OF LICENSING PROGRAM MANAGER: Cara Smith
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2025 03:00 PM - It Cannot Be Edited


Created By: Jaime Vado On 12/04/2025 at 12:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LA SELVA
FACILITY NUMBER: 435200383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2025
Section Cited
CCR
81088(e)(1)

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81088(e)(1) Fixtures, Furniture, Equipment, and Supplies - Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This regulation has not been met as evicdenced by:
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Facility shall create a plan of action oulining how this regulation will be corrected and met. Written plan is to be received by due date assigned.
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Based on the water temperature tested in the second floor client bathroom, the tempearture was measured at 130F. This exceeds the 120F maximum outlined in regulations. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cara Smith
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


LIC809 (FAS) - (06/04)
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