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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202577
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:42:31 PM


Document Has Been Signed on 04/12/2022 04:42 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:SOMERSET SENIOR LIVINGFACILITY NUMBER:
435202577
ADMINISTRATOR:CONNORS, SONIAFACILITY TYPE:
740
ADDRESS:1050 ST ELIZABETH DRTELEPHONE:
(408) 217-9775
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:40CENSUS: 0DATE:
04/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Sonia ConnorsTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced Case Management visit to conduct a facility closure tour. LPA Heberle met with Administrator Sonia Connors (Admin).

LPA toured the facility inside and out, including 40 out of 40 resident rooms. LPA did not observe any residents to be present at the facility. During visit, LPA obtained the original facility license. Admin confirmed that all residents had been moved out of the facility as of 04/06/2022, and had previously submitted facility closure plan to the regional office on 02/28/2022. All previous residents were confirmed to have been relocated.

No deficiencies were cited at this time as per California Code of Regulations Title 22. As of 04/12/2022, the facility license is no longer valid. LPA explained the closure process to licensee and provided licensee with a copy of this report and the facility closure letter.

This report was reviewed with Administrator Sonia Connors and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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