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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706162
Report Date: 08/13/2022
Date Signed: 08/13/2022 04:55:47 PM


Document Has Been Signed on 08/13/2022 04:55 PM - 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: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: 22DATE:
08/13/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Virgil Valin, ADM TIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Steve Chang, and Licensing Program Manager (LPM) Sarah Yip conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with Administrator (ADM) Virgil Valin.

The purpose of this TA Tele visit was to review the facility COVID-19 infection mitigation plan and facility inspection of physical plant to ensure plan is being carried out, and to provide support and guidance to the staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has COVID-19 signage at the main entrance door, and screening station with the following: screening questionnaire, hand sanitizer, thermometer, face masks, and a visitor log.

The facility has 4 buildings, each building has 2 bathrooms and 3 bedrooms. One building was used as isolation building, the whole build was as "red zone". The main kitchen and main dining room were in one building. The laundry area was in one building. The visiting room, office, bathrooms, bedrooms, kitchen , dinning room, laundry area and food storage area were observed and inspected. COVID posters were observed in the facility. Trash cans were observed with covers. Paper towels were observed with holders. Washing hands signage with washing hands for 20 seconds by the sinks in kitchen and bathrooms were observed. Isolation building/room signs were observed. PPE supplies/stations were observed outside the isolation rooms. Donning and doffing posters were not observed by the isolation rooms.

Based on today's inspection, below are the recommendations:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 HOME
FACILITY NUMBER: 430706162
VISIT DATE: 08/13/2022
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1. Facility to have signage of donning and doffing PPE by the isolation room PPE station.
2. Facility to wash the COVID negative first and last the COVID positive for laundry.
3. Facility to disinfect the washer and drier machine after the laundry for positive cases.
4. Facility to frequent wipe down common/ high touch areas with EPA grade disinfectants.
5. Facility to have facility staff wear N95 mask when taking care of positive resident.
6. Facility to use the highest temperature for positive cases’ laundry.
7. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates.
8.. PIN information: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/adult-senior-care.


No citation noted during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2022
LIC809 (FAS) - (06/04)
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