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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294284
Report Date: 05/21/2021
Date Signed: 05/28/2021 01:19:49 PM

Document Has Been Signed on 05/28/2021 01:19 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:ST. MARY'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435294284
ADMINISTRATOR:ARIMAS, MARILUZ & MERLINOFACILITY TYPE:
740
ADDRESS:1265 SOCORRO AVENUETELEPHONE:
(408) 390-4931
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 6CENSUS: 6DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Mariluz ArimasTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Licensee Mariluz Arimas.

LPA toured the facility with Licensee. One central entry point was designated for all staff, residents, and visitors. A screening station and sign in sheet were present at the entrance. Hand sanitizer was present.

All staff members were observed to be wearing masks.

COVID-19 signs and hand washing signs were present throughout the facility. All restrooms observed to be adequately stocked with paper towels and hand soap. Bathrooms observed having foot pedal operated trash bins.

Facility observed to have adequate supply of PPE in the storage area. A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) was in file. LPA discussed the practice of daily operation with Licensee.

No deficiency cited during visit. However, an advisory note was issued, see LIC 9102.

This report was reviewed with Licensee and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
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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