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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200183
Report Date: 08/24/2021
Date Signed: 08/25/2021 10:19:27 AM

Document Has Been Signed on 08/25/2021 10:19 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LILY AVENUE HOMEFACILITY NUMBER:
435200183
ADMINISTRATOR:AMY HELLYERFACILITY TYPE:
735
ADDRESS:1105 LILY AVENUETELEPHONE:
(408) 341-0400
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 6CENSUS: 5DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nina FranciscoTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Caregiver-in-Charge Joseph Megwe. Later came the House Manager Nina Francisco.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and questionnaire were present at the entrance.

LPA toured the facility. The facility was observed to be in sanitary condition. All staff members were observed to be wearing masks. There were COVID-19 signs throughout the facility.

LPA inspected 2 restrooms. The restrooms were observed to be adequately stocked with paper towels and hand soap. Trash bins with lids were present. Hand washing signs were present.

Facility was observed to have an adequate supply of PPE in the storage area. LPA discussed the infection control with the House Manager and the Administrator Amy Hellyer over the phone. LPA made recommendations and discussed the PIN 21-10-ASC. 4 out of 5 residents were fully vaccinated per Administrator. House Manager and Caregiver-in-Charge were fully vaccinated also.

Advisory note (LIC 9102) was issued. No deficiency cited during visit.

This report was reviewed with the House Manage.

A copy of this report and advisory note were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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