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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200157
Report Date: 10/03/2022
Date Signed: 10/03/2022 04:02:28 PM


Document Has Been Signed on 10/03/2022 04:02 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:SANDY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
435200157
ADMINISTRATOR:ZIPAGAN, AZUCENAFACILITY TYPE:
740
ADDRESS:550 TUSCARORA DRIVETELEPHONE:
(408) 472-2059
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 3DATE:
10/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Sandy ZipaganTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Licensee, Sandy Zipagan.

During visit, LPA toured the facility to include the kitchen, living room, residents rooms, bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. Facility temperature maintained at 78 degrees Fahrenheit.

Facility has a designated entry point for visitor sign in, symptom screening, and temperature check. Hand sanitizer available at entry. Bathrooms supplied with hand washing sign, and paper products. Facility staff clean and disinfect multiple times daily and as needed. LPA observed the facility's Personal Protective Equipment (PPE) supplies. LPA reviewed facility's procedures to isolation, visitation, and infection control training. Staff are not N95 fit tested. The following posters observed to include cover your cough, feeling ill, keeping the facility clean, symptoms of COVID, and hand washing sign.
LPA advised to remove PIN 21-40-ASC posted at the front door and inside the facility. LPA advised to reviewed PIN 22-28-ASC regarding the latest information on visitation.

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

This report was reviewed with Sandy Zipagan and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022
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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