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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708719
Report Date: 08/20/2021
Date Signed: 08/21/2021 09:14:26 AM

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:PRECIOUS MOMENTS RESIDENTIAL CARE HOME #2FACILITY NUMBER:
430708719
ADMINISTRATOR:CASEY, TERESITAFACILITY TYPE:
740
ADDRESS:1701 FOXWORTHY AVENUETELEPHONE:
(408) 978-3173
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 6DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Rachelle Reynolds, House MangerTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annually inspection and met with House Manger Rachelle Reynolds (RR).

Upon arrival at the facility main entrance, staff Beny Reyes (BR) took LPA's body temperature, asked LPA the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility with BR. There are 4 resident single rooms, 1 resident shared room, and 3 staff live-in rooms in the facility. LPA observed 6 residents (R1 - R6) in the bedrooms, living room, and family room. LPA observed two staff (S1, S2) in facility. COVID-19 posters were observed at the facility. LPA observed the staff wore the masks.

LPA inspected the facility food supplies. The two day perishable food and seven day nonperishable food supplies are sufficient. The facility room temperature was at 72 degree F. LPA observed hand sanitizer were at many places in the facility. LPA observed the beds in the resident shared room were 6 feet apart. LPA observed not all the trash bins in the facility are with covers. RR stated the facility will change all the trash cans to be with covers. Paper towels were observed with holder. RR stated all the staff and residents are fully vaccinated.

No citation were issued during today's inspection. Exit interview conducted with RR. This report was provided to RR to review and to sign. A copy of this report was emailed to RR.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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