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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202813
Report Date: 04/20/2021
Date Signed: 04/20/2021 01:20:04 PM

Document Has Been Signed on 04/20/2021 01:20 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:FOOTHILL CARE HOMEFACILITY NUMBER:
435202813
ADMINISTRATOR:OCAMPO, ROSSINI DEFACILITY TYPE:
740
ADDRESS:2641 MONTICELLO WAYTELEPHONE:
(408) 964-8340
CITY:SAN JOSESTATE: CAZIP CODE:
95051
CAPACITY: 6CENSUS: 0DATE:
04/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rossini De OcampoTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted a pre-licensing tele-inspection visit today via Zoom. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA met with Administrator (ADM) Rossini De Ocampo. The facility has an approved fire clearance for 5 non-ambulatory residents and 1 bedridden resident.

At around 10:05am, LPA toured the facility virtually with ADM. LPA advised ADM to make sure that prior to operating, COVID-19 related posters to promote social distancing and infection control are posted and a screening station is located by the entry door for any visitors, residents or personnel coming in through the facility. There were complaint, ombudsman, and resident's personal rights posters observed by the living room. The thermostat registered the room temperature at 70 deg F.

At around 10:10am, bedrooms and bathrooms were observed. Resident bedrooms were observed in good repair and with adequate lighting. There were two bathrooms at the home that were observed clean with proper lighting, non-skid mats and grab bars. Cabinets under the bathroom sinks for cleaning supplies were observed locked. The water temperature in the bathroom inside bedroom #4 was measured at 111.9 deg F.

The living and family rooms were observed in good repair and adequate lighting. The kitchen and dining area were observed. Refrigerator/freezer was in good working condition. There were two locked cabinets observed in the kitchen for sharps and cleaning supplies. The water temperature in the kitchen was measured at 110.2 degrees F. Continued on 809-C.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: FOOTHILL CARE HOME
FACILITY NUMBER: 435202813
VISIT DATE: 04/20/2021
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Two carbon monoxide (CO) detectors were observed, one by the hallway between bedrooms #1 and #2 and another by the kitchen. The CO detector by the hallway was tested and observed working. Smoke detectors by the hallways, living room, dining room and inside bedrooms #2 and #5 were all tested and observed working. There were two fire extinguishers observed at the home, one located across the hall and another between the dining area and kitchen which were both serviced on Sept 2020. Night lights were observed in hallways, common areas and bedrooms.

At around 10:40am, the backyard and grounds were observed. There were fencing around the home. All outdoor passageways were observed clear and free of obstruction. No bodies of water observed. The garage was observed with supplies, extra wheelchairs and walkers and a laundry area.

There were no issues noted during the pre-licensing tele-inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report sent to Rossini De Ocampo for review and signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC809 (FAS) - (06/04)
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