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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706169
Report Date: 02/13/2023
Date Signed: 02/13/2023 04:52:55 PM

Document Has Been Signed on 02/13/2023 04:52 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:ELLIOTTS HOMEFACILITY NUMBER:
430706169
ADMINISTRATOR:ELLIOTT, M & SFACILITY TYPE:
735
ADDRESS:2324 BEN HUR COURTTELEPHONE:
(408) 371-0195
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 2DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marlene ElliottTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with administrator (ADM) Marlene Elliott. Upon arrival, ADM took LPA body temperature, asked the questionnaires of infection control and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. COVID posters were observed at the main entrance and in facility. 2 residents were observed in facility.

LPA toured the facility inside and out with ADM. LPA inspected living room, family room, kitchen, dinning area, and laundry room. Knives closet, and cleaning product closet were observed locked. There are 2 bedrooms for residents, and two restrooms for residents. There are 4 bedrooms and two restrooms for ADM family. Paper towels were observed with holders, Some trash cans in facility were observed without covers. ADM stated the facility will replace the trash cans with covers within 5 days. Cloth towels were observed in kitchen and restrooms. No posters of washing hands for 20 seconds by the sinks in kitchen and restrooms, even though there were posters of washing hands in kitchen and restrooms. ADM stated the facility will replace the posters with posters of washing hands for 20 seconds within 5 days. Room temperature was observed at 69 degree F, and hot water temperature was observed at 106 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient. PPE supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 03/13/2022. LPA inspected the backyard, there was no obstruction to block the walkway. There was a swimming pool at backyard. There are fences with gates locked around the swimming pool. ADM stated all staff and residents are fully vaccinated and done with booster. ADM already submitted the Infection Control. Plan to LPA. No citation noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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