<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708478
Report Date: 12/27/2022
Date Signed: 12/27/2022 05:26:29 PM


Document Has Been Signed on 12/27/2022 05:26 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



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:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:07 PM
MET WITH:Administrator, Dhorydell SisonTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/27/2022 at 4:07pm, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection focusing on infection control. LPA met with Administrator (ADM), Dhorydell Sison.

During visit, LPA Rai toured the facility to include the living room, 4 resident rooms, 3 bathrooms, 1 staff room, kitchen, laundry area, dining area and exterior. All fire exit routes are free and clear of obstruction. All staff observed wearing a face covering. LPA observed 5 clients at the facility.

Facility has a designated entry point but ADM will create for sign-in, symptom screening, and temperature check for all visitors and staff. Hand sanitizer made available throughout the facility. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. LPA Rai observed facility's Personal Protective Equipment (PPE) supplies. Facility has procedures to isolation and testing for COVID-19. Staff are trained on infection control. Facility staff clean and disinfect multiple times daily and as needed. The following posters observed to include wash your hands and symptoms of COVID-19.Per ADM, the staff are not N95 fit tested, ADM will contact Concentra or a Health clinic for staff to be N95 fit tested. LPA Rai observed 2 out of the 3 bathrooms have the trash cans without lids. ADM will replace trash cans with lids.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Dhorydell Sison and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4