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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202368
Report Date: 05/28/2021
Date Signed: 05/28/2021 04:50:36 PM

Document Has Been Signed on 05/28/2021 04:50 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:CARMONT HOMEFACILITY NUMBER:
435202368
ADMINISTRATOR:RIZALDY CARREONFACILITY TYPE:
740
ADDRESS:1636 EDSEL DRIVETELEPHONE:
(408) 569-9236
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 6CENSUS: 3DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Rizaldy CarreonTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Infection Control site visit and met with Licensee Rizaldy Carreon.

LPA toured the inside the facility. COVID-19 screening station observed at the entrance of the facility. COVID-19 prevention and social distancing posters observed throughout the facility. Bedrooms, bathrooms, kitchen, dining area, and living room observed in good repair. Hallways were free and clear of obstructions. Hand washing signs and trash cans were observed in all bathrooms.

Medications, toxins, disinfectant supplies, and sharp objects were observed in locked cabinets and inaccessible to residents.

LPA observed an adequate supply of Personal Protective Equipment (PPE).
LIC 808/ Mitigation Plan obtained during visit.

No deficiency cited during visit.

This report was reviewed with Licensee Rizaldy Carreon and a copy was provided via email.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Karen Taku
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2021
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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