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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708648
Report Date: 12/29/2022
Date Signed: 12/29/2022 09:44:58 AM


Document Has Been Signed on 12/29/2022 09:44 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:FRIENDSHIP HOUSEFACILITY NUMBER:
430708648
ADMINISTRATOR:HAND, ELIZABETHFACILITY TYPE:
740
ADDRESS:1511 PRINCETON DRIVETELEPHONE:
(408) 665-0911
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 4DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee, Elizabeth SolorioTIME COMPLETED:
09:55 AM
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On 12/29/2022 at 8:45am, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection focusing on infection control. LPA met with Licensee Elizabeth Solorio.

During visit, LPA Rai toured the facility to include the family room, living room, 5 resident rooms, 4 bathrooms, 1 staff room, kitchen, laundry area, dining area and exterior. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Disinfectants and laundry detergents stored in a locked cabinet.

Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect twice daily and as often as needed. Bathrooms supplied with hygiene products and hand washing signs. Trash can with lid observed. LPA Rai observed a sufficient amount of Personal Protective Equipment (PPE) for 30 days. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient.

The following posters observed to include wash your hands, symptoms of COVID-19, social distancing and importance of wearing a mask.

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

This report was reviewed with Licensee Elizabeth Solorio 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: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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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