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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294193
Report Date: 05/06/2022
Date Signed: 05/06/2022 04:02:45 PM

Document Has Been Signed on 05/06/2022 04:02 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: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:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Roberto SuarezTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Roberto Suarez.

During visit, LPA Marrufo toured the facility inside and out. The facility had a visitor screening area. Three out of three bathrooms had available soap and paper towels and hand washing signs. LPA Marrufo observed a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed there to be a PPE supply of at least 30 days. The outdoor exits were clear of obstruction.

No deficiencies were 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: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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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