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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702352
Report Date: 12/14/2021
Date Signed: 12/14/2021 03:12:19 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:VALLEY PINESFACILITY NUMBER:
430702352
ADMINISTRATOR:HEINAN, JAMESFACILITY TYPE:
740
ADDRESS:545 EAST MAIN AVENUETELEPHONE:
(408) 779-2855
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:49CENSUS: 20DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Carolyn HeinanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Administrator Carolyn Heinan.

During visit, LPA toured the facility's interior and exterior to include the TV Room, dining room, resident rooms, resident bathrooms, hallways, staff bathrooms, and courtyard. Fire exits were free and clear of obstruction.

LPA observed a central entry point and hand sanitizer for all visitors, staff, and residents. Facility has a special visitor sign at the front entrance. LPA observed the bathroom to have supplies of paper towels, and soap available for staff, residents, and visitors. Facility disinfect and sanitize high touch surfaces daily and as needed. All staff and residents are fully vaccinated.

The Department will provide COVID-19 resources and PPE supplies for facility.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory Notes provided.

This report was reviewed with Administrator Carolyn Heinan and a copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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