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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202781
Report Date: 12/30/2021
Date Signed: 12/31/2021 10:13:39 AM

Document Has Been Signed on 12/31/2021 10:13 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:BAUTISTA HOMEFACILITY NUMBER:
355202781
ADMINISTRATOR:ANGELA BECERRA GAYTANFACILITY TYPE:
737
ADDRESS:777 OLYMPIATELEPHONE:
(831) 818-7981
CITY:SAN JAUN BAUTISTASTATE: CAZIP CODE:
95045
CAPACITY: 4CENSUS: 4DATE:
12/30/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:ANGELA BECERRA GAYTANTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Administrator, Angela Gaytan. During visit, LPA conducted a Facetime tour of the facility with PCC Roxane Fangon and LPM Romeo Manzano The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

LPA, PCC, and LPM toured the facility to include the central entry point, screening area, dining room, hallway, bathrooms, and backyard. All staff are N95 fit tested.

During today's tele-visit, the following recommendations were made to the facility by PCC Roxane Fangon:

1. Provide staff with a refresher on donning and doffing PPE
2. Remind staff of the importance of wearing a mask, frequent hand-washing, and maintaining social distancing
3. When needed, designate an isolation bathroom for COVID-19 positive residents

LPA will provide Administrator a link on donning and doffing PPE.

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with Angela Gayan Administrator via telephone and a copy of the report emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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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