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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200383
Report Date: 07/10/2023
Date Signed: 07/10/2023 11:20:16 AM

Document Has Been Signed on 07/10/2023 11:20 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 SELVAFACILITY NUMBER:
435200383
ADMINISTRATOR:JIM MILLSAPFACILITY TYPE:
772
ADDRESS:652 FOREST AVENUETELEPHONE:
(650) 323-1401
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY: 12CENSUS: 8DATE:
07/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Anthony MillerTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Anthony Miller, Director of Operations. The Case Management visit was due to an incident in which a resident left the facility and is suspected to have been deceased after being hit by a train as a pedestrian. The facility self-reported the incident on 07/06/2023 and the incident occurred 07/05/2023.

During visit, LPA Marrufo obtained copies of resident records for the involved resident and spoke with Director of Operations Anthony Miller.

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

This report was reviewed with Anthony Miller and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2023
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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