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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707150
Report Date: 01/21/2022
Date Signed: 01/21/2022 01:38:38 PM

Document Has Been Signed on 01/21/2022 01:38 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 HOME IIFACILITY NUMBER:
430707150
ADMINISTRATOR:ELLIOTT, MARLENEFACILITY TYPE:
735
ADDRESS:1594 INVERNESS CIRCLETELEPHONE:
(408) 723-9423
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 5DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tina MunozTIME COMPLETED:
01:00 PM
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At 11:00AM, licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with House Manger Tina Munoz (TM). .

Upon Arrival, TM took LPA's body temperature, asked infection control questionnaires, and checked LPA in the visitor log book. LPA observed the COVID posters in the facility. One staff and five residents were observed in facility.

LPA toured the facility with TM inside out. LPA inspected living room, family room, dinning room, kitchen. There are 2 restrooms, 3 resident shared rooms, and 2 staff live-in rooms in facility. Some trash cans without covers were observed in facility. Some paper towels without holders were observed. TM stated the facility will fix the issues in one day. TM stated the facility will remove the extra chairs in dinning room. Two days perishable foods and seven non perishable foods were observed sufficient. Fire extinguisher's service date was observed on 7/14/2021. Room temperature was observed at 68 degree F. Medication cabinet, Knife closet, and cleaning products closet were observed locked. PPE supplies were observed sufficient. Smoke dictators were tested and were working fine.

Front yard and back yard were inspected. No obstruction was observed to block the walkway.

TM stated all the residents and staff are fully vaccinated and done with booster shots.

No deficiency or allegation was issued today. Exit interview was conducted with TM. This report was provided to TM for signature. A copy of this report was emailed to TM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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