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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200383
Report Date: 11/01/2024
Date Signed: 11/01/2024 11:52:07 AM

Document Has Been Signed on 11/01/2024 11:52 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/
DIRECTOR:		JIM MILLSAPFACILITY TYPE:
772
ADDRESS:652 FOREST AVENUETELEPHONE:
(650) 323-1401
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY: 12CENSUS: 8DATE:
11/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Julia Phillips and Sajana SagarTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 11/01/24, Licensing Program Analysts (LPAs) Grace Donato & Kiran Jain conducted an unannounced case management visit. LPAs met with Julia Phillips, Director of Quality Improvement, Anthony Miller, Director of Operations, and Sajana Sagar, Director of Operations and LPAs explained the purpose of the visit.

An amended report and additional interviews, and record reviews were conducted in reference to complaint # 26-AS-20240930115429.



Report is reviewed and copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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