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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201306
Report Date: 04/12/2024
Date Signed: 04/12/2024 04:13:42 PM

Document Has Been Signed on 04/12/2024 04:13 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:HIDDEN LANE VILLAFACILITY NUMBER:
435201306
ADMINISTRATOR/
DIRECTOR:		THERESA CARRFACILITY TYPE:
740
ADDRESS:890 BERRY AVENUETELEPHONE:
(650) 254-0721
CITY:LOS ALTOSSTATE: CAZIP CODE:
94024
CAPACITY: 6CENSUS: 6DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Mercy CalilungTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Mercy Calilung, care giver.

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 two out of two hallway bathrooms and observed the water temperatures in the sinks to be 107 F and 109 F. Each bathroom had available soap and paper towels as well as working lights.

LPA Marrufo toured six out of six bedrooms and observed there to be functioning lights in each room as well as available bedding and clothing storage areas. The smoke detectors in each bedroom and in the hallways all functioned properly when tested.

LPA Marrufo toured the outside area and found the outside exit was clear of obstructions.

LPA Marrufo reviewed resident and staff records for residents R1-R6 and staff S1-S3. During record review, LPA Marrufo observed resident R3 was missing a Physician's Report and residents R1 and R6 were missing Safeguard for Property/Valuables forms.

Deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Mercy Calilung and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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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Document Has Been Signed on 04/12/2024 04:13 PM - It Cannot Be Edited


Created By: David Marrufo On 04/12/2024 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HIDDEN LANE VILLA
FACILITY NUMBER: 435201306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(10)
87506 (b) Each resident’s record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee did not ensure that during review of R1-R6’s resident records, resident R3’s resident record contained a Medical Assessment (Physician’s Report), which poses a potential safety risk to residents in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee agrees to submit a copy of R3’s Physician’s Report to CCL by Plan of Correction date.
Type B
Section Cited
CCR
87506(b)(16)
87506 (b) Each resident’s record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During record review of resident R1-R6’s records, residents R1 and R6 has missing Safeguard for Property/Valuables forms, which poses a potential safety risk to residents in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee agrees to submit copies of R1’s and R6’s Safeguard for Property/Valuables forms to CCL by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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