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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294340
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:31:47 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: 201DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Karen LernerTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced annual Required 1 Year visit and met with Karen Lerner.

During visit, LPA Marrufo toured the facility. The facility entrance had a visitor screening area. LPA observed the facility bathroom had signs related to COVID-19 and hand washing guidelines. LPA Marrufo observed the facility PPE supply and found the facility had a PPE supply of at least 30-days. LPA Marrufo observed the common areas in the Assisted Living and Memory Support sections of the facility and observed there to be socially distanced seating and COVID-19 related signs posted. LPA Marrufo observed the dinning areas in the Assisted Living and Memory Support areas. LPA Marrufo observed the facility kitchen and found there to be a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed facility staff to be wearing face coverings.

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

This report was reviewed with Karen Lerner and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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