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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202885
Report Date: 03/10/2023
Date Signed: 03/13/2023 08:40:19 AM

Document Has Been Signed on 03/13/2023 08:40 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:MERIDIAN VILLAFACILITY NUMBER:
435202885
ADMINISTRATOR:CORNELIA, GARYFACILITY TYPE:
740
ADDRESS:2755 MERIDIAN AVETELEPHONE:
(408) 802-0215
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 0DATE:
03/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:GARY CORNELIATIME COMPLETED:
11:55 AM
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Licensing Program Analysts (LPAs) Steve Chang, Manuel Monter, and Ravi Patel, conducted a pre licensing inspection visit, and met with administrator (ADM) GARY CORNELIA. COVID posters were observed on the main entrance door. Screening station was observed at the main entrance with thermometer, masks, hand sanitizer, visitor log book, and COVID questionnaires.

LPA toured the facility inside and out with ADM. LPA inspected living room, kitchen, dinning area, two restrooms, 4 bedrooms,, and laundry room. Three resident share bedroom, one staff live-in room were observed. Medication closet, was observed locked. Knives closet, and cleaning product closet were observed locked. One of the bed rooms were observed without screen. ADM stated ADM will put the screen on within 5 days. Trash cans were observed with covers. Posters of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. Bed room 3 is for the bedridden resident.

One of paper towels without holders was observed in restrooms. ADM stated ADM will put paper towels with holders in restrooms within 5 days. PPE supplies were observed sufficient. First Aid Kit was observed in the facility. Non-skid mats and Bars were observed in restrooms.

Room temperature was observed at 68 degree F, and hot water temperature was observed at 114 degree F.
The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm system. ADM tested the smoke and carbon monoxide detectors, and they were working fine. Fire extinguishers was serviced on 11/27/2022. LPA inspected the backyard, there was no obstruction to block the walkway.

ADM stated the staff are all fully vaccinated and done with booster. LPA discussed the Infection Control Plan with ADM. Component III orientation was conducted with ADM.

No citation noted today. Exit interview was conducted with ADM. This report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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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