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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708724
Report Date: 11/15/2021
Date Signed: 11/15/2021 03:58:52 PM

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:LINCOLN & PINE, WILLOW GLENFACILITY NUMBER:
430708724
ADMINISTRATOR:LIGAYA SEMANAFACILITY TYPE:
740
ADDRESS:1710 LINCOLN AVENUETELEPHONE:
(408) 265-6520
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 6DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Rose AbcedeTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced Annual Required 1 Year Infection Control site visit and met with Rose Abcede, Administrator.

LPA toured the facility inside and out to include but not limited to: kitchen, dining room, living room, bedrooms, bathrooms and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in a locked cabinet. Toxins, cleaning supplies, knives and sharp objects are secured. Interior temperature 75 degrees Fahrenheit.

In the kitchen LPA observed a minimum of 3 day perishable food supply and 7 day non perishable food supply.

Facility observed to have designated entry point for universal symptom screening. Administrator will conduct in house staff training on visitor screening protocols. All restrooms observed to be supplied with hygiene products. Hand washing signs were posted in bathrooms. Hand sanitizer available to residents. Facility observed to have adequate supply of Personal Protective Equipment (PPE). Staff observed wearing masks.

LPA reviewed the facility policies and procedures to include screening, isolation, disinfecting, staffing, training, supplies, PPE usage and social distancing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Rose Abcede, Administrator and a copy provided,
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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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