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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200298
Report Date: 05/19/2021
Date Signed: 05/20/2021 07:56:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:JENNISON CAREFACILITY NUMBER:
435200298
ADMINISTRATOR:NOLASCO, ROSITA D.FACILITY TYPE:
740
ADDRESS:878 NIEVES STREETTELEPHONE:
(408) 263-1323
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:6CENSUS: 6DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rosita NolascoTIME COMPLETED:
11:45 AM
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Licensing Program Analyst Marybeth Donovan conducted an unannounced infection control site visit on 05/19/2021 at 10:00am. LPA met with facility Administrator Rosita Nolasco.

LPA toured the facility inside and out to include the entry, 4 bedrooms and 2 bathrooms, kitchen, dining room, living room, laundry, storage area and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in a locked cabinet in the dining room. Knives and sharp objects and locked in a cabinet underneath the kitchen sink. Toxins and cleaning supplies stored in a locked cabinet in the laundry room.

All staff members observed to be wearing masks. No residents in facility observed to be wearing masks. LPA advised Administrator to encourage residents to wear masks when in close quarters in common area. The facility serves developmentally delayed residents.

Facility observed to have designated entry point for universal symptom screening with questionnaire. All restrooms observed to be supplied with hygiene products. Hand washing signs were posted in both bathrooms. Hand sanitizer available to residents if needed. Bathrooms contained foot pedal operated trash cans.

Facility observed to have adequate supply of Personal Protective Equipment (PPE).

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

LPA reviewed report with Administrator Rosita Nolasco and a copy emailed due to technical issues for signature.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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