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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294340
Report Date: 09/03/2021
Date Signed: 09/03/2021 04:33:32 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:MOLDAW FAMILY RESIDENCES AT 899 CHARLESTONFACILITY NUMBER:
435294340
ADMINISTRATOR:ELYSE GERSONFACILITY TYPE:
741
ADDRESS:899 EAST CHARLESTON ROADTELEPHONE:
(650) 433-3600
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:270CENSUS: 228DATE:
09/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elyse GersonTIME COMPLETED:
10:45 AM
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Licensing Program Manager (LPM) Jackie Jin, Licensing Program Analyst (LPA) David Marrufo, and Nurse Cristina Wong conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Elyse Gerson and Wellness Director Gabriella Brigham.


The Administrator reports that there are currently 8 COVID-19 positive residents and 4 COVID-19 positive staff. During today's tele-visit, the following recommendations were made to the facility by Nurse Cristina Wong:

1. Remind staff to label cleaning spray bottles with expiration dates
2. Ensure no more than 2 households in an elevator at a time
3. Continue training staff regarding donning and doffing of PPEs
4. Continue training staff regarding wiping down surfaces
No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed with Wellness Director Gabriella Brigham. A copy of the report will be sent to her for it to be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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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