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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294315
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:20:46 PM

Document Has Been Signed on 03/28/2022 04:20 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:KEENE KARE IIIFACILITY NUMBER:
435294315
ADMINISTRATOR:GAMBOA, ABIGAILFACILITY TYPE:
740
ADDRESS:4629 ROYAL FOREST COURTTELEPHONE:
(408) 616-0615
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 2DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:CRISTINA BANAGOTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) CRISTINA BANAGO. Upon arrival, ADM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. ADM stated the facility will put more COVID posters on in 7 days. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. Living room, family room, kitchen, dinning room and two restrooms were inspected. Trash cans were observed without covers. ADM stated the facility will replace all the trash can with covers in 3 days. Cloth towels were observed in kitchen. ADM removed the cloth towels in kitchen, and placed more paper towels in kitchen. Paper towels were observed with holders. Two single resident bedrooms, and laundry room were inspected. Three bedrooms are used by ADM family. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 105 degree F in facility. Two residents were observed in facility.

The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ADM. The smoke detectors were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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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