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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708478
Report Date: 11/22/2021
Date Signed: 11/22/2021 09:19:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:SANTO NINO RESIDENTIAL CARE HOME #1FACILITY NUMBER:
430708478
ADMINISTRATOR:DHORYDELL SISONFACILITY TYPE:
740
ADDRESS:105 CLAYTON AVENUETELEPHONE:
(408) 295-4112
CITY:SAN JOSESTATE: CAZIP CODE:
95110
CAPACITY:6CENSUS: 5DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Teodora SisonTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPAs) Marybeth Donovan and Christine Dolores conducted an unannounced Required - 1 Year Annual inspection to include Infection Control site visit. LPAs met with Teodora Sison Licensee and toured the facility inside and out.

LPAs observed a central entry point. Facility has 3 shared rooms with beds 6 feet apart. Bathrooms have supplies of paper towels and soap available for staff, residents, and visitors. Hand washing signs posted in the bathrooms and in the kitchen. Trash cans were observed covered with lids. LPAs observed a supply of PPEs. Facility staff disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19.

LPAs discussed training, masks, donning and doffing of PPEs, N95 Fit Testing, disinfecting, isolation and reporting requirements.

The Department will provide supply of additional PPEs to the facility.

No deficiencies cited during today's visit. Advisory notes provided to the Licensee regarding COVID 19 screening guidelines and documentation of the screening process.

This report was reviewed with Teodora Sison Licensee and a copy emailed due to technical issues.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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