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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200689
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:04:48 PM

Document Has Been Signed on 06/20/2023 03:04 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WOODSIDE RESIDENTIAL CARE FACILITY FOR ELDERLYFACILITY NUMBER:
019200689
ADMINISTRATOR:MIRRIAM PARASFACILITY TYPE:
740
ADDRESS:20531 FOREST AVENUETELEPHONE:
(510) 538-7262
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 14CENSUS: 14DATE:
06/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Lucille CincoTIME COMPLETED:
03:15 PM
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On this day at around 2:45 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit to follow up on the two residents that needed immediate placement from Montgomery Springs Manor. LPA spoke with Administrator Mirriam Paras on the phone and she authorized staff Lucille Cinco to sign the report.

LPA observed there were 2 caregivers and one cook during the shift. LPA interviewed Resident 1 and Resident 2. They both said they are fine. Physician's Reports for both residents indicate they have Dementia. They both look clean and well-kempt.

LPA did not observe any immediate health and safety issues during the visit.

A copy of this report was provided to staff Cinco.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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