<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202668
Report Date: 02/14/2023
Date Signed: 02/14/2023 02:02:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/14/2023 02:02 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 IFACILITY NUMBER:
435202668
ADMINISTRATOR:SAZON, DEBBIEFACILITY TYPE:
740
ADDRESS:819 GAIL AVETELEPHONE:
(408) 738-1400
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 6CENSUS: 5DATE:
02/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Debbie SazonTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with Administrator (ADM) Debbie Sazon. Upon arrival, ADM took LPA body temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. LPA observed 5 residents and 4 staff in facility.

LPA toured the facility inside and out with ADM. LPA inspected living room, kitchen, dinning area, and laundry room. Medication closet, knives closet and cleaning product closet were observed locked. There are 6 bedrooms for residents, and two staff live-in room in facility. 2 bathrooms are in facility. Paper towels were observed with holders, Trash cans were observed with covers. Posters of washing hands for 20 seconds were observed by the sinks in kitchen and restroom. Room temperature was observed at 72 degree F, and hot water temperature was observed at 118 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 02/23/2022. LPA inspected the backyard, there was no obstruction to block the walkway. ADM stated all staff and residents are fully vaccinated and done with booster. ADM stated the facility already submitted the Infection Control. Plan to CCL office.

No citation noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1