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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209141
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:18:18 PM

Document Has Been Signed on 11/01/2022 02:18 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: 3DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator, Marisela VizcarraTIME COMPLETED:
02:37 PM
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On 11/1/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Marisela Vizcarra (AD), who arrived a short time later. LPA met with AD.

LPA conducted a facility tour with AD. COVID-19 guidelines are in place. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors at facility entrance. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lids. Hand washing posters were observed by the bathroom sink. Bedrooms are double occupant. Beds were observed to be at least 6 feet apart.

LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident records were reviewed for updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/15/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Marisela Vizcarra, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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