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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209141
Report Date: 10/20/2021
Date Signed: 10/20/2021 05:58:26 PM

Document Has Been Signed on 10/20/2021 05:58 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PALO ALTO SENIOR CARE HOMEFACILITY NUMBER:
107209141
ADMINISTRATOR:TORRE VIZCARRA, MARISELAFACILITY TYPE:
740
ADDRESS:269 W. PALO ALTO AVETELEPHONE:
(310) 866-8628
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 4DATE:
10/20/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marisela Torre Vizcarra, LicenseeTIME COMPLETED:
01:45 PM
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On 10/20/21 at 11:00 AM, Licensing Program Analysts (LPAs) Malia Thao and Mai Yang arrived announced to conduct a Pre-Licensing inspection.

LPA toured inside and outside of facility. No obstructions observed. All bedrooms have sufficient furniture and lighting. Grab bars observed for use of toilets and showers in hallway and master bathrooms. Non-skid mats observed for both showers. Hot water measured 116.6 degrees F. Facility set at comfortable temperature. Fire extinguisher was last serviced 3/9/21. Smoke and carbon monoxide combination detector tested and operational. Dishware and utensils observed. Centrally stored medication observed in locked kitchen cabinet. Chemicals observed in locked hallway closet. First aid kit observed complete.

The following will need to be brought into compliance:
1. Master bath: Re-caulk inside shower base and clean soap scum off full tile surround, top to bottom.
2. Hallway bath: Re-caulk toilet base.

Licensee will need to contact LPA once items are completed. LPA will need to return for a follow-up inspection. Comp III completed.

Exit interview conducted. A copy of this report was emailed to Licensee with "Read receipt" to confirm receipt of this report.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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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