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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200664
Report Date: 09/15/2021
Date Signed: 09/16/2021 08:59:07 AM

Document Has Been Signed on 09/16/2021 08:59 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MARIA'S HOMEFACILITY NUMBER:
435200664
ADMINISTRATOR:ROY, MARIA G.FACILITY TYPE:
735
ADDRESS:1038 RAWLINGS DRIVETELEPHONE:
(408) 622-5598
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Rubenita Sandoval, ADMTIME COMPLETED:
03:39 PM
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At 2:20PM, Licensing Program Analyst (LPA) Steve Chang arrived at the facility. Upon arrival, staff Recto Sandoval (RS) conducted an infection control/prevention screening, and took LPA's body temperature, then checked LPA into the visitor log book.

LPA addressed the purpose of today's visit to administrator (ADM) Rubenitia Sandoval. LPA toured the facility inside out with RS. LPA observed 5 clients (C1 - C5) and 4 staff (S1 - S4) in the facility. LPA inspected the kitchen, family room, dining room and two and half restrooms. The COVID posters were observed in the facility and at main entrance. There are 1 shared room, 4 single rooms, and two staff live-in rooms in the facility.

Current rosters of staff and clients were obtained. The paper towels with holders, and the trash cans with covers were observed. LPA inspected the food supplies. Two days perishable foods, and seven days non perishable foods were observed sufficient. Medication cabinet was observed locked. PPE supplies were observed sufficient. Front yard and backyard were inspected, no any obstruction was observed.

ADM stated all the residents and staff are fully vaccinated. LPA reviewed and discussed LIC808 with ADM, ADM stated the facility will follow the COVID protocol.

No citation was issued for today's inspection. Exit interview was conducted with ADM. This report was provided to ADM to review and to sign. A copy of this report was emailed to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2021
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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