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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200945
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:58:48 PM

Document Has Been Signed on 01/20/2023 02:58 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DEAN COURT HOMEFACILITY NUMBER:
079200945
ADMINISTRATOR:CRUZ, JENNYFACILITY TYPE:
735
ADDRESS:200 DEAN COURTTELEPHONE:
(650) 892-4647
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jonathan Bentulan, LicenseeTIME COMPLETED:
03:10 PM
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On 01/20/2023 at 11:45 AM, Licensing Program Analyst (LPA), L. Ibo arrived announced to conduct an infection control annual inspection. LPA met with S2, LPA explained the purpose of the visit. LPA called licensee Jonathan Betulan ; LPA explained the purpose of the visit. Jonathan arrived at the facility around 1:40PM. Facility has census of 4.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of four (4) total bedrooms which three (3) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Visitors’ policy is posted on the front entrance. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. Smoke detectors and carbon monoxide were in operating condition during visit.

Facility has enough supplies of PPEs, paper supplies and hygiene supplies. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiency cited during the visit.

Exit interview conducted. Copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
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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