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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707150
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:49:30 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/26/2023 04:49 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: 4DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Loren GarciaTIME COMPLETED:
11:02 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with House Manger Loren Garcia (HM). .

Upon Arrival, HM took LPA's body temperature, and checked LPA in the visitor log book. LPA observed the COVID posters in the facility.

LPA toured the facility with HM inside and out. LPA inspected living room, family room, dinning area, kitchen. There are 2 restrooms, 3 resident shared rooms, and 2 staff live-in rooms in facility. Trash cans were observed with covers in facility. Paper towels were observed with holders. Posters of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. Two days perishable foods and seven nonperishable foods were observed sufficient. Fire extinguisher's service date was observed on 5/13/2022. Room temperature was observed at 68 degree F, and hot water temperature was observed at 110 degree F. Medication cabinet, Knife closet were observed locked. PPE supplies were observed sufficient. Smoke dictators were tested and were working fine. Dish washer liquid were observed on the top of the kitchen sink, HM stated the facility will put the Dish washer liquid under the sink and locked in 3 days.

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

HM stated all the residents and staff are fully vaccinated and done with booster shots. The facility submitted the Infection Control Plan to LPA.

No citation was issued today. Exit interview was conducted with HM. This report was provided to HM for signature. A copy of this report was provided to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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