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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200551
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:52:46 PM

Document Has Been Signed on 04/21/2022 04:52 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SAINT DOMINIC MANORFACILITY NUMBER:
435200551
ADMINISTRATOR:NAVARRO, ILUMINADAFACILITY TYPE:
735
ADDRESS:1828 ROCHELLE DRIVETELEPHONE:
(408) 371-2698
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 5DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH: ILUMINADA NAVARROTIME COMPLETED:
12:39 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) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) ILUMINADA NAVARRO. Upon arrival, staff Hayzel Morales (HM) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with HM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and two restrooms were inspected. Trash cans were observed without covers in kitchen, restrooms. ADM stated the facility will put the trash cans with covers in kitchen and restrooms in 3 days. Paper towel in kitchen and restrooms were observed with holder. There were no washing hands for 20 seconds signs by the sinks in kitchen and restrooms. ADM stated the facility will put the signage on in kitchen and restrooms in 3 days. 4 single resident bedrooms, 1 shared resident bedroom, 1 staff live-in room, and laundry room were inspected. The beds in shared room were observed 6 feet apart. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 108 degree F in facility. Four residents were observed in facility.

Fire extinguisher was serviced on 04/13/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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