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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294193
Report Date: 05/16/2023
Date Signed: 05/16/2023 04:00:58 PM


Document Has Been Signed on 05/16/2023 04:00 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
CENTRAL COAST CR/RES, 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: 5DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ofelia GuazonTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Assistant Administrator Ofelia Guazon.

During visit, LPA toured the inside and outside of the facility. The facility kitchen area had a perishable food supply of 2 days and a non-perishable food supply of 7 days. The first aid kit was found to be complete. Chemical cleaning supplies were locked in a cabinet in the garage. 2 out of 2 facility bathrooms had water temperatures of 108 F and 110 F. Each bathroom had available soap, paper towels, and non-skid mats.

LPA Marrufo observed 6 out of 6 resident bedrooms and observed each room to have available bedding, drawers, and functioning lighting. LPA Marrufo tested the smoke detectors in each bedroom and hallway. Each smoke detector functioned properly when tested.

LPA Marrufo toured the outside of the facility and the outdoor exits were clear of obstructions.

LPA Marrufo reviewed the Centrally Stored Medication Logs, Resident Records, and Staff Records, and all were found to be complete.

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

This report was reviewed with Assistant Administrator Ofelia Guazon and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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