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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708648
Report Date: 12/07/2021
Date Signed: 12/07/2021 03:16:13 PM

Document Has Been Signed on 12/07/2021 03:16 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:FRIENDSHIP HOUSEFACILITY NUMBER:
430708648
ADMINISTRATOR:HAND, ELIZABETHFACILITY TYPE:
740
ADDRESS:1511 PRINCETON DRIVETELEPHONE:
(408) 665-0911
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 5DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Elizabeth Solorio, ADMTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit today, and met with administrator (ADM) Elizabeth Solorio. Upon arrival, staff Maria Delourdes (MD) took LPA's body temperature. MD did not asked LPA the infection control questionnaires. LPA observed the COVID posters at the main entrance and in facility.

LPA toured the facility inside out with ADM. Living room, family room, dinning room, and kitchen were inspected. Two resident shared rooms, two resident single rooms, one staff live-in room, one empty resident room, and four restrooms were inspected. The beds in the shared room were observed 6 feet apart. Not all trash cans were with covers. ADM stated the facility will fix this issue in 3 days. ADM stated the facility will put more paper towels with holders in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed not sufficient for 30 days. ADM stated the facility will buy more PPEs. Medication closet, knives closet, cleaning product closet were observed locked. Room temperature was observed at 71 degree F. Hot water temperature was observed at 110 degree F.

Fire extinguisher was serviced on 12/07/2021. LPA observed the workers finished it and left facility. The facility was equipped with smoke and carbon monoxide detectors, and fire alarm. Front yard and backyard were inspected. There was no obstruction observed to block the walkways. ADM stated all the staff and residents are fully vaccinated and all are scheduling for the booster shots.

No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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