<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209141
Report Date: 10/27/2021
Date Signed: 10/27/2021 11:04:13 AM

Document Has Been Signed on 10/27/2021 11:04 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
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:
10/27/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maribel Torre Vizcarra, LicenseeTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/27/21 at 10:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived announced to conduct a follow-up pre-licensing inspection. LPA met with Licensee (LIC) Maribel Torre Vizcarra and was granted entry.

LPA observed master bath shower base re-caulked and tile surround cleaned, and hall bath toilet base re-caulked.

All pre-licensing requirements have been met. LPA will notify CAB in Sacramento for final review prior to license being issued.

Exit interview was 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: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1