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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200930
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:18:57 PM


Document Has Been Signed on 06/10/2024 04:18 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:VI AT PALO ALTOFACILITY NUMBER:
435200930
ADMINISTRATOR:JOHN KOSELAKFACILITY TYPE:
741
ADDRESS:620 SAND HILL ROADTELEPHONE:
(650) 853-5000
CITY:PALO ALTOSTATE: CAZIP CODE:
94304
CAPACITY:876CENSUS: 585DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Valerie AlvesTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Valerie Alves, Care Center Administrator.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the facility kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo toured the locked storage areas for cleaning supplies and the laundry areas. LPA Marrufo reviewed the first aid kit and found it to be complete.

LPA Marrufo toured the facility hallway bathrooms and 7 resident bathrooms. The water temperatures in the bathrooms ranged from 105 F - 115 F. Each bathroom had available soap and paper towels as well as working lights.

LPA Marrufo toured 7 resident bedrooms and observed each bedroom to have functioning lights and available beds and clothing storage areas.

LPA toured the outside area and found the exits to be clear of obstructions.

LPA Marrufo reviewed the Automatic Fire Alarm System Inspection Log and found the smoke detector system was last tested on May 1st, 2024. LPA Marrufo toured 7 resident Centrally Stored Medication Logs and found them to be complete. LPA Marrufo reviewed 7 resident files and 7 staff files.

The last Emergency Disaster Drill was conducted on May 28th, 2024.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Valerie Alves and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
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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