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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200664
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:29:59 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/24/2022 03:29 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: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:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Rubenita Sandoval, ADMTIME COMPLETED:
02:03 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Rubenita Sandoval. Upon arrival, staff Recto Sandoval (S1) took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and in the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Family room, kitchen, dinning room and three restrooms were inspected. All trash cans were observed with covers. Some paper towels were observed without holders. ADM stated the facility will put the paper towels with holders in 3 days. No poster of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. ADM stated ADM will put the posters of washing hands for 20 seconds by the sinks in kitchen and restrooms in 3 days. 4 single resident bedrooms, 1 shared resident bedroom and laundry room were inspected. Two staff live-in rooms were observed in facility. 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 78 degree F, and hot water temperature was at 110 degree F in facility. 3 residents and 3 staff were observed in facility.

Fire extinguisher was serviced on 01/06/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, 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 and done with booster. ADM already submitted the Infection Control Plan to LPA.

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: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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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