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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202411
Report Date: 03/22/2022
Date Signed: 03/22/2022 03:49:26 PM

Document Has Been Signed on 03/22/2022 03:49 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:KINGMAN CARE HOME LLCFACILITY NUMBER:
435202411
ADMINISTRATOR:ANTHONY CASIMFACILITY TYPE:
740
ADDRESS:1426 KINGMAN AVENUETELEPHONE:
(408) 945-9197
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 6DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Avelina PascuaTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control and met with house manager, Avelina Pascua.

During visit, LPA toured the facility inside and outside to include the dining room, kitchen resident rooms, bathrooms, laundry room, activity room, garage, and backyard. All fire exit routes were free and clear of obstructions. All staff are observed to be wearing a face mask.

Facility has a central entry point and hand sanitizer available for all residents, staff, and visitors. Bathrooms observed to have supplies of paper supplies, hygiene products, and hand washing sign. Trash cans were observed with lid. LPA observed facilities Personal Protective Equipment (PPE). Staff are trained on donning and doffing PPE. Facility has an isolation plan for residents who are symptomatic or test positive with COVID-19. The following posters were observed to include, special visitors, cough etiquette, symptoms of COVID, social distancing, droplet precaution, and staff sick leave. Facility disinfect and sanitize high touch surfaces daily and as needed.

During visit, LPA advised to remove the "no visitors allowed" poster at the front door. LPA informed staff of the visitor policy. The following documents were obtained during visit to include, LIC308, Administrator Certificate, and LIC610E.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Avelina Pascua and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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