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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 09/28/2021
Date Signed: 09/28/2021 03:29:05 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: 11DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Claudia EliasTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced annual required inspection. LPAs met with Lisa Lanford, MedTech/Caregiver, and Claudia Elias, Patient Care Supervisor.

During today's visit LPAs toured the facility inside and outside. LPAs observed a central entry point and screening area for all visitors and staff.

Bathrooms have supplies of paper towels and soap available for staff, residents, and visitors. Trash cans were observed covered with lid. LPAs observed the following posters, cough etiquette, social distancing, visitor policy, hand washing, and COVID-19 everyday precaution. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19.

During tour LPAs observed disinfectant and cleaning supplies under bathroom sinks in the hallway. Toxins were removed and secured during time of visit. Advisory note provided.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Claudia Elias, Patient Care Supervisor. Copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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