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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600751
Report Date: 07/22/2021
Date Signed: 07/22/2021 07:03:05 PM

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:HOME AT CRESTMOORFACILITY NUMBER:
415600751
ADMINISTRATOR:PRADO, IMELDAFACILITY TYPE:
740
ADDRESS:2600 PLYMOUTH WAYTELEPHONE:
(650) 872-8419
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Imelda PradoTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Imelda Prado.

At 11:45 AM, LPA entered the facility through the facility's central entry point and was screened by staff. At 11:55 AM, a tour of the facility was conducted. COVID-19 postings were observed. Staff were observed wearing face coverings. Residents were observed having lunch in the communal dining room.

The facility has at least 30 days' supply of personal protective equipment (PPE) including face shields, isolation gowns, gloves, and face masks. Hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable foods and at least 1 week's supply of non-perishable foods are available in the premises.

According to Administrator, the facility has achieved 100% vaccination rate against COVID-19 for both residents and staff. The facility is currently accepting visitors inside the facility.

The facility's mitigation plan was received by Community Care Licensing.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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