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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200391
Report Date: 07/07/2022
Date Signed: 07/07/2022 11:13:23 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/07/2022 11:13 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:EMPLOY AMERICAFACILITY NUMBER:
435200391
ADMINISTRATOR:MERITA AMITUANAIFACILITY TYPE:
775
ADDRESS:124 BLOSSOM HILL RD, STE. FTELEPHONE:
(408) 574-3950
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 45CENSUS: 3DATE:
07/07/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Nai SaechaoTIME COMPLETED:
11:07 AM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced annual inspection on 07/07/2022 at 10:02am and met with Personal Plan Facilitator Nai Saechao(Admin).

LPA toured the facility. The facility is currently operating in a reduced capacity due to the COVID-19 pandemic, offering online services to many of its clients. LPA toured the reception area, activity room, movie room, 2 bathrooms, isolation room, and 3 offices. The facility currently has clients attending the program. LPA was screened for temperature upon entrance into the facility at the designated entry point, but not screened for symptoms. All staff members observed to be wearing masks.

No prohibited items noted in facility. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. Food is not offered to clients at the facility, nor is medication administered at the facility. Fire extinguishers observed to have been inspected in April of 2022.

All restrooms stocked with paper towels. Hand washing signs observed in all bathrooms. Facility water temperature measured at 116.9 *F. Social distancing signs observed to be posted in all public areas. Facility was observed to have a designated room for residents to isolate in the event of manifestation of symptoms. Vaccination rate for staff and clients is currently at 100%.

No deficiencies cited during today's visit. This report was reviewed with Admin Personal Plan Facilitator Nai Saechao and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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