<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200334
Report Date: 07/25/2022
Date Signed: 07/25/2022 04:55:09 PM


Document Has Been Signed on 07/25/2022 04:55 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:PRINCESS CARE HOME #4FACILITY NUMBER:
435200334
ADMINISTRATOR:JUDITH MORALESFACILITY TYPE:
740
ADDRESS:1537 ILIKAITELEPHONE:
(408) 264-1240
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 5DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Randy CabreraTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with lead staff, Imelda Nool and Administrator, Randi Cabrera.

During visit, LPA toured the inside and outside of the facility to include the dining room, resident rooms, bathrooms, kitchen, and backyard. All fire exit routes were free and clear of obstruction. All staff observed to be wearing a face mask. All staff and residents are fully vaccinated and boosted.

Facility has a designated central entry point to include symptom screening and temperature check for all visitors and staff. Bathrooms supplies with paper supplies, hygiene products, and hand washing sign. The facility has a designated visitation area. Facility staff clean and disinfect multiple times daily and as needed. LPA observed the facility's Personal Protective Equipment (PPE) supplies. Staff has been provided training on infection control to include PPE use. LPA reviewed facility's procedures to isolation and visitation. Staff has been provided N95 fit testing.

The following posters observed to include social distancing, symptoms of COVID, stop the spread of germs, cough etiquette, and droplet precaution.

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

This report was reviewed with Administrator, Randi Cabrera 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: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1