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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200383
Report Date: 01/30/2024
Date Signed: 01/30/2024 01:46:24 PM

Document Has Been Signed on 01/30/2024 01:46 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:JIM MILLSAPFACILITY TYPE:
772
ADDRESS:652 FOREST AVENUETELEPHONE:
(650) 323-1401
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY: 12CENSUS: 11DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sajana SagarTIME COMPLETED:
02:00 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 Sajana Sagar, Director of Residential Operations.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area and food storage areas in the facility basement. LPA observed a perishable food supply of two days and a non-perishable food supply of 7 days. LPA Marrufo observed a complete first aid kit. LPA Marrufo observed locked storage areas for sharp objects and cleaning supplies.

LPA Marrufo 4 out of 4 resident bedrooms and observed there to be working lights and available bedding and clothing storage. The smoke detectors and carbon monoxide detectors in the resident bedrooms and hallways functioned properly when tested.

LPA Marrufo toured three out of three resident bathrooms and observed available soap and paper towels and functioning lights. The water temperature measured at 120 F.

The outdoor area was toured and the exits were clear of obstructions.

LPA Marrufo reviewed resident and staff records, including Centrally Stored Medication Logs, and found them to be complete.

This report was reviewed with Sajana Sagar and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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