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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 08/13/2020
Date Signed: 08/14/2020 04:00:47 PM

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:VILLA SERENA OF MORGAN HILLFACILITY NUMBER:
435202754
ADMINISTRATOR:ELSOUSOU, NICOLASFACILITY TYPE:
740
ADDRESS:16095 CHURCH STREETTELEPHONE:
(408) 778-5683
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:20CENSUS: 8DATE:
08/13/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Nicolas ElsousouTIME COMPLETED:
05:00 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
On August 13, 2020 at 3:30pm, Licensing Program Analysts (LPA) Karen Taku conducted an unannounced Pre-Licensing Tele-visit, via ZOOM. Due to COVID19 preventative measures, the Department has suspended on-site inspections. LPA met with Administrator (Admin) Nicolas Elsousou & Patient Care Supervisor (PCS) Georgina Ruiz and explained the purpose of the visit. The facility currently has 8 residents in care.

The facility was toured inside and out. Living room and Bedrooms were observed with adequate lighting and furniture. Bathrooms are in proximity to resident bedrooms, and showers are equipped with grab bars and non-skid mats & flooring. Dining area observed clean and furnished. Kitchen observed with ample preparation space and a large refrigerator. LPA observed a 2-day supply of perishable and 7-day supply of non-perishable foods. All indoor and outdoor pathways are free of obstruction. No bodies of water on the premises.

Facility temperature observed at 78 degrees. Hot water temperature complies. Toxic substances and cleaning supplies were observed locked in the hallway closet. Mobile medication care was observed locked. Smoke alarm and carbon monoxide detector were observed, tested, and operational. Facility has a Sprinkler System. Fire extinguisher was serviced on 2/12/2020. First Aid kit observed complete with manual, thermometer, scissors, tweezers, and bandages. Resident and staff records were reviewed and complete.

Component III orientation was conducted with the Administrator. Based on LPA observation, the facility is approved for licensure, pending the final review of the facility's application by Centralized Application Bureau (CAB).

No deficiencies were cited during today's visit.
This report was reviewed with the Admin, and a copy was sent via email for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020
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