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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200183
Report Date: 10/26/2022
Date Signed: 10/26/2022 11:23:19 AM

Document Has Been Signed on 10/26/2022 11:23 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:LILY AVENUE HOMEFACILITY NUMBER:
435200183
ADMINISTRATOR:AMY HELLYERFACILITY TYPE:
735
ADDRESS:1105 LILY AVENUETELEPHONE:
(408) 341-0400
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 6CENSUS: 3DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Amy HellyerTIME COMPLETED:
11:25 AM
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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 staff, Rodgers Mutaawe and Administrator, Amy Hellyer.

During visit, LPA toured the facility with staff to include the living room, dining room, resident rooms, bathrooms, kitchen, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff observed wearing a face mask.

Facility has a designated entry point for symptom screening and temperature check for all visitors and staff. LPA recommended to place the latest PIN for visitation at the main entrance. Hand sanitizer made available at entry and throughout facility. Bathrooms supplied with hand washing sign, hygiene products, and paper supplies. Facility staff clean and disinfect multiple times daily and as needed. Facility staff document resident's symptoms and temperature daily. LPA reviewed facility's procedures to visitation. Staff are trained on infection control. Staff are not N95 fit tested but facility staff are working on completing the fit test. LPA observed facility's Personal Protective Equipment (PPE) supplies and advised to retain at least a 30 day supply of all PPE at the facility. Administrator states to have an adequate amount of PPE supplies located in their main office, but will work on moving some PPE supplies to the facility. The following posters observed to include social distancing, hand washing, and keep facility clean.

No deficiencies were cited per California Code of Regulation, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Amy Hellyer and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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