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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201306
Report Date: 04/25/2022
Date Signed: 04/25/2022 10:40:51 AM

Document Has Been Signed on 04/25/2022 10:40 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HIDDEN LANE VILLAFACILITY NUMBER:
435201306
ADMINISTRATOR:THERESA CARRFACILITY TYPE:
740
ADDRESS:890 BERRY AVENUETELEPHONE:
(650) 254-0721
CITY:LOS ALTOSSTATE: CAZIP CODE:
94024
CAPACITY: 6CENSUS: 6DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ofelia GuanzonTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Ofelia Guanzon.

During visit, LPA Marrufo toured 6 out of 6 bedrooms, 2 out of 2 hallway bathrooms, kitchen, living room area, hallways, and outdoor area. LPA Marrufo observed a visitor screening area at the facility entrance, signs advising visitors to wear masks, hand washing signs in the bathrooms along with available soap and paper towels, and the storage rooms had available PPEs.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Ofelia Guanzon and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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