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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435200383
Report Date:
09/20/2022
Date Signed:
09/20/2022 11:10:09 AM
Document Has Been Signed on
09/20/2022 11:10 AM
- 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 SELVA
FACILITY NUMBER:
435200383
ADMINISTRATOR:
JIM MILLSAP
FACILITY TYPE:
772
ADDRESS:
652 FOREST AVENUE
TELEPHONE:
(650) 323-1401
CITY:
PALO ALTO
STATE:
CA
ZIP CODE:
94301
CAPACITY:
12
CENSUS:
6
DATE:
09/20/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Alex Dillard
TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Alex Dillard.
The facility bathroom had available soap and paper towels. Hand washing posters were posted in the bathroom. A perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days were observed. A 30-Day supply of PPEs were observed. Cleaning supplies were also observed. The outdoor area was toured and the exits were clear of obstructions.
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with Administrator Alex Dillard and a copy of the report was provided.
SUPERVISORS NAME
:
Sarah Yip
LICENSING EVALUATOR NAME
:
David Marrufo
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/20/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/20/2022
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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