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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294193
Report Date: 05/24/2021
Date Signed: 05/24/2021 03:48:50 PM

Document Has Been Signed on 05/24/2021 03:48 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:EL SERENO HOMEFACILITY NUMBER:
435294193
ADMINISTRATOR:CARR, THERESA R.FACILITY TYPE:
740
ADDRESS:2080 EL SERENO AVENUETELEPHONE:
(650) 968-8400
CITY:LOS ALTOSSTATE: CAZIP CODE:
94024
CAPACITY: 6CENSUS: 6DATE:
05/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Roberto SuarezTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced COVID-19 Infection Control Visit and met with Roberto Suarez.

LPA Marrufo toured 6 out of 6 resident bedrooms, 2 out of 2 bathrooms, hallways, dinning areas, kitchen, outdoor area, and outdoor storage unit. LPA Marrufo observed facility bathrooms with available soap, paper towels, and garbage cans with lids.

LPA Marrufo observed a supply of PPEs stored in the outdoor storage unit and in the facility home. LPA Marrufo observed a visitor sign-in station with hand sanitizer and a sign-in log tracking temperature and symptoms of each visitor.

No deficiencies cited at this time as per California Code of Regulations Title 22.


This report was reviewed with Roberto Suarez and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2021
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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