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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201306
Report Date: 04/01/2026
Date Signed: 04/01/2026 02:11:51 PM

Document Has Been Signed on 04/01/2026 02:11 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:
04/01/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Assistant Administrator, Ofelia Guanzon TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On April 1, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspection. LPA met with Assistant Administrator, Ofelia Guanzon and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility. There are six resident bedrooms, all of which are single private rooms. Resident rooms were observed to be clean with all required furniture. Two full bathrooms and one half bathroom was observed to be clean, odor-free and in good repair. Water temperature throughout the facility measured between 104-108.7 degrees F. Auditory alarms on exit doors were observed to be in good working condition.

Dining room was observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed two day perishables, however did not observe seven day non-perishables. Medications, sharps, and chemicals were observed locked an inaccessible to residents in care. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of April 2026. Emergency drills are logged and done every three month. LPA reviewed 5 resident records and 5 staff records. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. Failure to correct the deficiencies may result in civil penalties. A copy of civil penalty is provided. Report is reviewed with Assistant Administrator and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: Cowan April
NAME OF LICENSING PROGRAM ANALYST: Komal Curley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2026
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/01/2026 02:11 PM - It Cannot Be Edited


Created By: Komal Curley On 04/01/2026 at 01:43 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: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, water temperature throughout the facility measured between 104-108.7 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee/administrator to send LPA video/photo of hot water temperature for all 4 sinks at the facility within regulatory requirements.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/01/2026 02:11 PM - It Cannot Be Edited


Created By: Komal Curley On 04/01/2026 at 01:43 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: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, LPA observed two staff records without health screening and one staff record with a health screening that was done more than six months prior to employement, ] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee/administrator shall conduct a personnel file audit and ensure all staff have health screenings. Licensee/administrator shall ensure if staff don't have health screenings, that one is done and maintained in staff files. Licensee/administrator shall submit the 3 staff health screenings to LPA by 4/8/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 04/01/2026 02:11 PM - It Cannot Be Edited


Created By: Komal Curley On 04/01/2026 at 01:43 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: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed two days perishables, however did not observe seven days non-perishables which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee/administrator shall send LPA a photo of 7-day non-perishables and ensure a supply of 7-day non-perishable is maintained at the facility at all times.
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(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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Based on resident record reviewed, two/five resident files were observed to not have their safeguard of personal property and valuables documentation in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee/administrator to complete the Safeguard of Personal Property and Valuables for the two residents and submit a copy to LPA by 4/8/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 04/01/2026 02:11 PM - It Cannot Be Edited


Created By: Komal Curley On 04/01/2026 at 01:43 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: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on resident records reviewed, one/five resident files did not have a signed admissions agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensee/administrator to send LPA a copy of the signed admissions agreement to LPA by 4/8/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
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