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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294128
Report Date: 02/24/2022
Date Signed: 02/24/2022 12:03:02 PM

Document Has Been Signed on 02/24/2022 12:03 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:CLARK'S VILLAFACILITY NUMBER:
435294128
ADMINISTRATOR:CLARK, DINA D.FACILITY TYPE:
740
ADDRESS:947 HOWARD AVE.TELEPHONE:
(408) 310-2647
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Milagros BaltazarTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection and met with caregiver, Milagros Baltazar.

During today's visit LPA toured the facility inside and outside to include dining room, living room, resident rooms, bathrooms, kitchen, garage, and backyard. Facility has 4 resident rooms, 2 bathrooms, and 1 staff room. All staff observed to be wearing a surgical mask.

Facility observed to have designated entry point for COVID-19 symptom screening for all visitors and staff. Bathrooms observed to be supplied with hygiene products and paper supplies. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE). Toxins, cleaning supplies, knives and sharp objects are secured.

LPA observed the following posters to include symptoms of COVID-19, respiratory symptoms, and required mask. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility staff are trained on infection control to include donning and doffing. Staff are N95 fit tested. Facility has a mitigation plan in place to prevent the spread of COVID-19.
No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory Notes provided.

This report was reviewed with caregiver, Milagros Baltazar and a copy of this report was provided
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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