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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202640
Report Date: 04/13/2021
Date Signed: 05/04/2021 10:12:28 AM

Document Has Been Signed on 05/04/2021 10:12 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CJCP RCFEFACILITY NUMBER:
435202640
ADMINISTRATOR:GONZAGA, MARITESFACILITY TYPE:
740
ADDRESS:678 HIGH GLEN DRTELEPHONE:
(408) 770-9453
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 5DATE:
04/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marties GonzagaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Steve Nguyen and HFEN, Angela Brand, conducted a Technical Assistance (TA) with Administrator(AD) Marites Gonzaga. The TA was conducted in order to help facilitate and assist with the latest Covid protocols according to CDC, PHD, and CCLD guidelines.

LPA inspected the facility inside and out. Covid + resident currently has own room. Facility will ensure that beds are six feet apart to maintain social distancing in rooms that are shared. Per Administrator, staff will redirect residents when necessary to follow Covid19 mitigation guideline. During meal times, residents will dine at designated spot/ staggered time to maintain social distancing. Observed medical and cleaning supplies in the facility is locked separate in secured cabinet. Staffing is maintained and PPE is stocked. Per AD, there are no covid symptoms among staff and residents at this time

Based upon the observations, the following recommendations were issued by the HFEN:

Use or make a screening form with the signs and symptoms on it.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE:
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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