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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202667
Report Date: 02/23/2022
Date Signed: 02/23/2022 04:00:38 PM

Document Has Been Signed on 02/23/2022 04:00 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:AT HOME SENIOR CARE IIFACILITY NUMBER:
435202667
ADMINISTRATOR:SAZON, DEBBIEFACILITY TYPE:
740
ADDRESS:825 GAIL AVETELEPHONE:
(408) 738-1400
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 6CENSUS: 6DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Ellen San FelipeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with House Manager (HM) Ellen San Felipe. Upon arrival, HM took LPA body temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. COVID posters were observed at the main entrance and in facility. 1 staff and 6 residents were observed in facility.

LPA toured the facility inside out with HM. LPA inspected living room, kitchen, dinning area, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked. There are 6 resident single rooms, each one with restroom. There are 2 staff live-in room in facility. The are two common restrooms in facility. Non skid mats were observed in each restroom. Cloth towels were observed in kitchen. HM removed the cloth tower in kitchen. Some paper towels were observed without holders. Some trash cans were observed without covers. There was no washing hands posters by the sink in kitchen. HM stated the facility will fix these issues in two days. Room temperature was observed at 72 degree F, and hot water temperature was observed at 108 degree F. 2 days perishable food supplies and 7 days nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. HM tested the smoke and carbon monoxide detectors, and they were working fine. LPA inspected the backyard, there was no obstruction to block the walkway. HM stated all staff and residents are fully vaccinated and done with booster.

No deficiency or issue noted during inspection. Exit interview was conducted with HM. This report was provided to HM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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