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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200698
Report Date: 07/21/2021
Date Signed: 07/21/2021 05:26:31 PM

Document Has Been Signed on 07/21/2021 05:26 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:EMBEE MANORFACILITY NUMBER:
435200698
ADMINISTRATOR:MANTILLAS, EDNAFACILITY TYPE:
735
ADDRESS:5867 EMBEE DRIVETELEPHONE:
(669) 234-3601
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Edna BautistaTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Edna Bautista.

At 2:18 PM, LPA entered the facility through the facility's central entry point and was screened by staff. At 2:25 PM, a tour of the facility was conducted with staff. Present during inspection were 5 residents and 2 staff. Staff were observed wearing face coverings. Residents' bedrooms, bathrooms, and common areas were inspected.

Hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable food and at least 1 week's supply on non-perishable food supply was observed in the premises. Personal protective equipment (PPE) and disinfection supplies were available in the premises.

Per Administrator, all residents and staff are fully vaccinated against COVID-19. The facility is currently accepting visitors inside the facility and residents have meals in the dining room. The facility's COVID-19 mitigation plan has been received and reviewed by the Department.

Exit routes were observed clear and unobstructed. The facility is equipped with smoke detectors, fire extinguishers, and a carbon monoxide detector.

No deficiencies were cited. Exit interview conducted with Edna Bautista and a copy of this report was provided during visit.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Gladys Kuizon
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
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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