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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707831
Report Date: 03/28/2024
Date Signed: 03/28/2024 10:06:35 PM

Document Has Been Signed on 03/28/2024 10:06 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
Lookup Error,
, CA
FACILITY NAME:LITTERAL HOUSEFACILITY NUMBER:
430707831
ADMINISTRATOR:CHRISTINA ROSSIFACILITY TYPE:
772
ADDRESS:96 SOUTH 14TH STREETTELEPHONE:
(408) 998-3293
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 14CENSUS: 14DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Christina RossiTIME COMPLETED:
04:15 PM
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On 3/28/24, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Christina Rossi. LPA explained the purpose of the visit.

LPA toured the facility and no obstructions were observed. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be fully furnished with adequate lighting. Room temp is at 72 degF. Sharps and toxic materials were observed to be locked. Food supply was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill which is done every month.

Five resident records and five staff records were reviewed. Staff have current First Aid/CPR certifications on file. Resident records were reviewed and were observed to be complete.

Medication review was done, and centrally stored medication is updated, medication is locked in a cabinet and inaccessible to residents.

No deficiencies are cited at this time. Report is reviewed and a copy is provided
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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