435202882-1-20-2023-26-AS-CDOS-CN9STP-20230120130953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202882
Report Date: 01/20/2023
Date Signed: 01/20/2023 01:10:07 PM

Document Has Been Signed on 01/20/2023 01:10 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	BROOKWOOD TERRACE HOME ONE		FACILITY NUMBER:	435202882
ADMINISTRATOR:	TEODORO, ARIELLE		FACILITY TYPE:	740
ADDRESS:	319 S. 23RD STREET		TELEPHONE:	(408) 883-2000
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY: 6		CENSUS: 5	DATE:	01/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Arielle and Alvin Teodoro		TIME COMPLETED:	01:15 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) Christine Dolores arrived unannounced to conduct the facility's pre-licensing visit. LPA met with Licensee, Alvin Teodoro and Administrator, Arielle Teodoro. There are currently residents living in the facility. The facility has 5 bedrooms and 2 bathrooms. The facility has an approved fire clearance for 6 ambulatory residents. LPA toured the facility to include the kitchen, living room, dining room, resident rooms, bathrooms, storage area, and exterior. Facility's exit routes were free and clear of obstruction. Resident rooms were equipped with proper furniture to include a bed, dresser, night stand, and lighting. Facility temperature was maintained at 65 degrees Fahrenheit. Bedding and linens are available to the residents and observed clean. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and paper supplies. Facility is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured at 114 degrees Fahrenheit in the kitchen. Facility has a designated locked cabinet with centrally stored medications. LPA reviewed 5 out of 5 residents centrally stored medication records with residents medications. LPA observed first aid kit with the following supplies: bandages, scissors, and tweezers. LPA observed the facility has a thermometer and was advised to place a thermometer inside the first aid kit. LPA observed the sharp objects and cleaning supplies were secured. See LIC809D.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BROOKWOOD TERRACE HOME ONE	FACILITY NUMBER: 435202882
	VISIT DATE: 01/20/2023

NARRATIVE

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LPA observed 2 days worth of perishables and 7 days worth of nonperishable. Refrigerator temperature was maintained at 37 degrees Fahrenheit. Freezer temperature was maintained at 0 degrees Fahrenheit.

Facility is equipped with smoke detectors, carbon monoxide detectors, and fire extinguisher that was last serviced on 11/07/2022. Hallway and passageways were observed free of obstruction.

The following posters were observed to include: personal rights, if you see something say something, ombudsmen, and resident right to counsel posted, and posters for infection control.

LPA reviewed 6 resident files and 3 staff files. Facility staff are fingerprint cleared. Resident files all consist of Admission Agreement, Medical Assessment with TB Information, Care Plans, Safeguard for Cash Resources, and Personal Rights. Staff files all consist of Personal Record, Health Screening with TB Information, and Criminal Record Statement.

Component III was conducted during visit with Administrator, Arielle Teodoro

No issues noted during this pre-licensing inspection. Facility was provided technical assistance. Please see LIC9102.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Administrator, Arielle Teodoro and a copy of this report provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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