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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200712
Report Date: 08/17/2021
Date Signed: 08/18/2021 02:48:19 PM

Document Has Been Signed on 08/18/2021 02:48 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:CAMARGO HOMEFACILITY NUMBER:
435200712
ADMINISTRATOR:NAPOLEON FRANCISCOFACILITY TYPE:
735
ADDRESS:1911 CAMARGO DR.TELEPHONE:
(408) 941-0712
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Ma Lorena OliverosTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Caregiver-in-Charge Ma Lorena Oliveros.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and hand sanitizer were present at the entrance.

LPA toured the facility. The facility was observed to be in sanitary condition. All staff members were observed to be wearing masks.

LPA inspected 2 restrooms. The restrooms were observed to be adequately stocked with paper towels and hand soap. Trash bins with lids were present.

Facility was observed to have a supply of PPE in the storage area. LPA discussed the infection control with the Caregiver-in-Charge and made recommendations. All 6 residents and 8 staff were fully vaccinated per Caregiver-in-Charge.

Advisory notes (LIC 9102) were issued. No deficiency cited during visit.

This report was reviewed with the Caregiver-in-Charge.

A copy of this report and advisory notes were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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