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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200827
Report Date: 12/28/2022
Date Signed: 12/28/2022 04:21:52 PM

Document Has Been Signed on 12/28/2022 04:21 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:YELLOW ROSE RESIDENTIAL CARE HOMEFACILITY NUMBER:
435200827
ADMINISTRATOR:BANGOY-REGALADO, REYLENFACILITY TYPE:
735
ADDRESS:1303 CARTERWOOD PLACETELEPHONE:
(408) 506-6478
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Reylen Bangoy-RegaladoTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Reylen Bangoy-Regalado.

During visit, LPA toured the facility to include the living room, bedrooms, bathrooms, kitchen, and backyard. All fire exit routes are free and clear of obstruction. All staff present observed wearing a face covering. All staff present are fingerprint cleared and associated to the facility.

Facility has a central entry point for symptom screening, temperature check, and sign-in for all visitors. Visitation guidelines posted at entry. Administrator removed the no visitor sign immediately. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. LPA observed facility's Personal Protective Equipment (PPE) supplies. Facility has procedures to isolation, visitation, and testing for COVID-19. Facility staff clean and disinfect multiple times daily and as often as needed. Administrator will work on training staff on the updated infection control plan. Staff are not N95 fit tested but the Administrator has plans to conduct N95 fit testing.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Administrator, Reylen Bangoy-Regalado and a copy of the report was emailed to Administrator due to printer issues.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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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