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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202415
Report Date: 06/07/2021
Date Signed: 06/07/2021 02:41:40 PM

Document Has Been Signed on 06/07/2021 02:41 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
CCLD Regional Office,
, CA
FACILITY NAME:CASA ALICE CARE HOMEFACILITY NUMBER:
435202415
ADMINISTRATOR:PING JING ZHAOFACILITY TYPE:
740
ADDRESS:809 ALICE AVENUETELEPHONE:
(650) 279-7488
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY: 6CENSUS: 4DATE:
06/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Becky BiTIME COMPLETED:
03:00 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 COVID-19 Infection Control Required 1 Year visit and met with Becky Bi.

During visit, LPA Marrufo toured six out of six resident bathrooms, hallways, dinning and common areas, outdoor visiting area, kitchen area, and resident bedrooms. Staff were observed wearing surgical masks.

LPA Marrufo observed that 6 out of 6 bathrooms did not have trash cans with foot-operated lids. LPA observed the facility entrance way did not have a log to screen visitor symptoms. LPA Marrufo observed that the facility has not yet submitted an LIC808 Mitigation Plan. Becky Bi also stated that the facility does not document daily temperature and COVID-19 symptom checks amongst residents and staff.

LPA Marrufo observed the facility has an adequate supply of PPEs.

Advisory Notes were issues. See LIC9102s for more information.

No Deficiencies were cited at this time as per California Code of Regulations, Title 22.

This report was reviewed with Becky Bi and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2021
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