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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200924
Report Date: 09/28/2021
Date Signed: 09/28/2021 12:57:27 PM

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:GILROY ELDERLY CARE HOMEFACILITY NUMBER:
435200924
ADMINISTRATOR:CLARK, DINAFACILITY TYPE:
740
ADDRESS:415 LONDON DRIVETELEPHONE:
(408) 847-4645
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:6CENSUS: 5DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Dina ClarkTIME COMPLETED:
01:10 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced annual required inspection. LPAs met with Dina Clark, Administrator.

During today's visit LPAs toured the facility inside and outside. LPAs observed a central entry point and screening area for all visitors and staff. Residents were observed to be eating lunch during the time of visit, to include meat and vegetables. Facility has 6 private resident rooms, 1 staff room, and 4 bathrooms.

Bathrooms have supplies of paper towels and soap available for staff, residents, and visitors. LPAs observed the following posters, social distancing, sick leave policy, and hand washing. Facility has a sufficient amount of PPE supplies to last 30 days. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19.

LPAs will send COVID-19 posters to post throughout the facility, to include COVID-19 screening symptoms.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Dina Clark, Administrator. Copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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