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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708150
Report Date: 06/26/2024
Date Signed: 06/26/2024 11:56:10 AM

Document Has Been Signed on 06/26/2024 11:56 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
Lookup Error,
, CA
FACILITY NAME:COLLEGE MANORFACILITY NUMBER:
430708150
ADMINISTRATOR/
DIRECTOR:
CORA REYESFACILITY TYPE:
740
ADDRESS:760 LEIGH AVENUETELEPHONE:
(408) 293-3745
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 5DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Dominica OlivaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 6/26/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator, Dominica Oliva. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area & garage. The indoor and outdoor passageways were free of obstruction. Staff is clearing out wood planks and other trash due to garbage pick up this morning. LPA observed some residents were in the dining room having snacks and watching tv. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility has a certified administrator, certificate still pending status. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA requested the following: Certificate of Liability Insurance and LIC500. LPA received LIC308.

No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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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