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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294193
Report Date: 05/21/2024
Date Signed: 05/21/2024 11:37:17 AM


Document Has Been Signed on 05/21/2024 11:37 AM - 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: 6DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Luisa RomanTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Luisa Roman.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the facility kitchen area and observed the kitchen to have locked drawers for medications and sharps.

LPA Marrufo toured three out of three resident bathrooms and observed the water temperatures to be 115 F, 114 F, and 113 F. Each bathroom had available soap and paper towels as well as functioning lights.

LPA Marrufo toured six out of six resident bedrooms. Each bedroom had working lights, available bedding and clothing storage areas. LPA Marrufo tested the smoke detectors in each bedroom and hallway as well as two out of two carbon monoxide detectors. All detectors functioned properly when tested.

LPA Marrufo reviewed the Centrally Stored Medication Logs, resident records, and staff records during visit.

The Emergency Disaster Drill Log states the last drill was conducted on 04/28/2024.

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

This report was reviewed with Luisa Roman and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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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