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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707808
Report Date: 04/28/2022
Date Signed: 04/28/2022 11:13:18 AM

Document Has Been Signed on 04/28/2022 11:13 AM - 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:HOPE REHABILITATION SERVICES - PARKMOORFACILITY NUMBER:
430707808
ADMINISTRATOR:JUAN GUELFACILITY TYPE:
775
ADDRESS:1555 PARKMOOR AVENUETELEPHONE:
(408) 282-0449
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 60CENSUS: 20DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Nga AuTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Program Manager Nga Au. LPA observed no clients on site. The facility has 20 clients participating in virtual day program. Clients resume in-person program by cohorts Monday and Tuesday.

During visit, LPA observed the entry, classroom, bathroom, kitchen, and quarantine room. All fire exit routes were free and clear of obstructions. Toxins, cleaning supplies and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening for all clients, staff, and visitors. Tables are socially distanced in the classroom for two clients per table divided by a plexiglass. All clients have their own supply / activity bin. Bathrooms observed to be supplied with hygiene products and paper supplies. Hand washing signs were posted in bathrooms and throughout facility. Hand sanitizer available upon entry and throughout the facility. LPA observed supply of Personal Protective Equipment (PPE). Staff have been trained on COVID-19 prevention, to include donning and doffing PPE. Facility's COVID-19 prevention program safety plan is posted in the common areas for review. LPA observed the quarantine room to include a trash can with lid and reviewed the policy and procedure for isolation. Facility clean and disinfect daily and as needed. The following posters observed to include required mask, social distancing, cover your cough and sneeze, and prevent the spread of COVID-19.

LPA informed Program Manager to review PIN 22-13-ASC and to submit Infection Control Plan to CCLD by 06/30/2022.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Program Manager, Nga Au and a copy of the report will be emailed.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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