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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200924
Report Date: 09/19/2022
Date Signed: 09/19/2022 03:35:55 PM


Document Has Been Signed on 09/19/2022 03:35 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: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: 6DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Dina ClarkTIME COMPLETED:
03:40 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, Dina Clark.

During visit, LPA toured the facility to include the bedrooms, bathrooms, living room, kitchen, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility. Sharp objects and medication observed secured. Facility temperature maintained at 75 degrees Fahrenheit. LPA observed 2 days worth of perishables and 7 days worth of non-perishable foods.

Facility has a designated entry point for symptom screening and temperature check for all visitors. LPA advised staff should document symptom screening and temperature check prior to starting their shift. Hand sanitizer made available at entry. Bathrooms supplied with hand washing sign, paper supplies, and hygiene products. LPA observed facility's Personal Protective Equipment (PPE) supplies. Trash can with lid observed. LPA reviewed the facility's procedures to isolation, testing, training, and visitation. Staff are N95 fit tested. The following posters observed to include symptoms of COVID, required mask, and social distancing.

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

This report was reviewed with Administrator, Dina Clark and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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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