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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200943
Report Date: 03/02/2022
Date Signed: 03/03/2022 08:24:29 AM

Document Has Been Signed on 03/03/2022 08:24 AM - 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,
, CA
FACILITY NAME:CARASTON CARE HOMEFACILITY NUMBER:
435200943
ADMINISTRATOR:ORIBELLO, EDNAFACILITY TYPE:
735
ADDRESS:2730 CARASTON WAYTELEPHONE:
(408) 223-7088
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Darren IgnacioTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Darren Ignacio Direct Support Professional.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the family room.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathroom observed to be supplied with hygiene products. Hand Washing signs posted in the bathroom and in the kitchen near the sinks. Hand sanitizer available to visitors and residents. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Stop Must Wear a Mask, Visitor Policy, COVID 19 Screening Symptoms, Face Mask's Do's and Don'ts, Droplet Precautions, Steps to Prevent the Spread of COVID 19, Social Distancing, and Practice Good Health Habits.

LPA reviewed the facility policies and procedures to include visitation, screening, masking, isolation and disinfecting.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Darren Ignacio Direct Support Professional and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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