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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 01/27/2021
Date Signed: 02/09/2021 08:55:19 AM

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: 9DATE:
01/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Georgina RuizTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Karen Taku and Program Clinical Consultant (PCC) Roxanne Fangon, conducted a virtual tele-visit via ZOOM, to provide technical assistance to prevent and mitigate the spread of COVID-19 within the facility. LPA met with Administrator Nicolas Elsousou and Patient Care Coordinator Georgina Ruiz.

During today's tele-visit, no recommendations were made. COVID-19 prevention measures were observed throughout the facility. Per PCC, the facility is doing well at mitigating the spread of COVID-19.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021
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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