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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706162
Report Date: 06/23/2021
Date Signed: 06/30/2021 10:25:37 AM

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:AMOR RESIDENTIAL CARE HOMEFACILITY NUMBER:
430706162
ADMINISTRATOR:VALIN, AMOR & VIRGILFACILITY TYPE:
740
ADDRESS:32 NORTH 21ST STREETTELEPHONE:
(408) 971-4244
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:24CENSUS: 21DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Virgil ValinTIME COMPLETED:
03:45 PM
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On 06/23/2021 at 2:30 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced Annual Required 1 Year visit. LPA met with Administrator Virgil Valin.

LPA toured the facility beginning with the main entrance. The entrance had a thermometer, hand sanitizer, and sign-in log to document temperature. Screening questions were asked but not documented. LPA recommended screening questions to be documented. Universal precautions, COVID-19 protocols, and social distancing guidelines were posted throughout the facility. Restrooms had hand soap readily available. Hand washing sign was posted at all hand washing stations.

Staff were observed wearing a mask and following COVID-19 protocols. Facility observed to have adequate supply of PPE.

No deficiencies were cited during today's visit.

Technical Assistance was provided during today's visit, see LIC 9102.

This report was reviewed with Administrator Virgil Valin and a copy was provided to Administrator Virgil Valin.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna BuiTELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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