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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708150
Report Date: 06/28/2022
Date Signed: 06/28/2022 12:12:44 PM

Document Has Been Signed on 06/28/2022 12:12 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:COLLEGE MANORFACILITY NUMBER:
430708150
ADMINISTRATOR:CORA REYESFACILITY TYPE:
740
ADDRESS:760 LEIGH AVENUETELEPHONE:
(408) 293-3745
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 5DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Dominica OlivaTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Licensee Dominica Oliva.

During visit, LPA toured the facility to include the resident rooms, bathrooms, living rooms, kitchen, and backyard. Toxins and sharp objects were observed secured.

Facility has a designated entry point for all visitors to include sign-in, symptom screening and temperature check. Hand sanitizer made available upon entry and throughout the facility. Bathrooms observed supplies with hygiene products, paper products, and hand washing sign. Trash can observed covered with lid. LPA observed Personal Protective Equipment (PPE). LPA advised to keep an adequate amount of PPE supplies in the facility at all times. Facility staff clean and disinfects multiple times daily and as needed. Staff are trained on infection control. Staff are scheduled for N95 fit testing on July 11, 2022. Facility has a procedure for visitation, LPA advised to refer to PIN 22-07-ASC. The following posters observed to include cough etiquette, symptoms and warning signs of COVID, and visitor guidelines.

LPA observed the sliding door in the living room which is used for emergency exit in disrepair, making it difficult to slide open. During visit, staff repaired the sliding door.

Updated documents were obtained to include the LIC610 and LIC308. Licensee will send LPA the updated Administrator certificate and LIC500.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with the Licensee and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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