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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702959
Report Date: 05/11/2022
Date Signed: 05/11/2022 11:39:03 AM


Document Has Been Signed on 05/11/2022 11:39 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:JULIET STEPHEN REST HOMEFACILITY NUMBER:
430702959
ADMINISTRATOR:OLIVA, DOMINICAFACILITY TYPE:
740
ADDRESS:909 COLLEGE DRIVETELEPHONE:
(408) 298-9502
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:6CENSUS: 5DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:OLIVA, DOMINICATIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual inspection to focus on infection control and met with Administrator, Dominica Oliva.

During visit, LPA toured the inside and outside of the facility to include the entrance, common areas, dining room, kitchen, resident rooms, bathrooms, garage, and backyard.

Facility has a designated entry point for COVID-19 symptom screening for residents, staff, and visitors. Staff monitor residents temperature and symptoms twice daily. Bathrooms observed to be supplied with hygiene products, paper supplies, and hand washing signs. LPA observed facility to have a trash can with lid. LPA observed supply of Personal Protective Equipment (PPE). Facility staff clean and disinfect multiple times daily and as needed. Facility is allowing visitors. LPA advised to remove the no visitors allowed sign at the main entrance. LPA reviewed facility's policies and procedures to isolation and infection control training. The following signs were observed to include symptoms of COVID, stop the spread of germs, droplet precaution, and feeling ill.

LPA informed Administrator to submit Infection Control Plan to CCLD by 06/30/2022 and review PIN 22-13-ASC.

No deficiencies issued per the California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Dominica Oliva 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: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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