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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601127
Report Date: 05/15/2024
Date Signed: 05/15/2024 09:11:54 PM

Document Has Been Signed on 05/15/2024 09:11 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SERRA HIGHLANDS SENIOR LIVINGFACILITY NUMBER:
415601127
ADMINISTRATOR/
DIRECTOR:		SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:501 KING DRIVETELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 120CENSUS: 62DATE:
05/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Administrator, Shayan GheisarTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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 May 15, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced continuation visit for an annual inspection that was conducted on 4/23/2024. LPA met with the administrator and explained the purpose of today's visit.

During today's visit:

A review of (6) resident files was conducted and noted on the LIC 858.
A review of (7) staff files was conducted and noted on the LIC 859.

LPA also conducted staff and residents interviews.

No deficiency cited. This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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