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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200943
Report Date: 05/26/2022
Date Signed: 06/01/2022 05:08:44 PM

Document Has Been Signed on 06/01/2022 05:08 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: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:
05/26/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alma BuclatinTIME COMPLETED:
10:53 AM
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On 05/26/22 Licensing Program Analyst Ryker Heberle (LPA), Licensing Program Manager Sarah Yip (LPM), and Program Clinical Consultant Helen Shi (PCC) conducted a case management tele-visit via Facetime to provide technical assistance in response to the facility's recent COVID outbreak. LPA, LPM, and PCC met with facility House Manager Alma Buclatin (Admin).

Admin gave Licensing a tour of the facility. PCC, LPA, and LPM noted the following recommendations during inspection:
  1. All staff shall be wearing PPE while providing care for residents
  2. Post signs on front door indicating that the facility is currently an isolation area, as well as donning and doffing instructions for entering staff.
  3. Start using disposable dishes/silverware, remove reusable gloves and only use disposable gloves
  4. Establish PPE donning station outside front door of the facility
  5. Remove reusable wash cloths/loofahs from facility bathrooms until direct use
  6. Replace all lidless trash cans with lidded trash cans
  7. Post hand washing sign in employee bathroom
  8. Place trash bags in laundry hampers
  9. Set up trash can for discarding of used PPE
No deficiencies cited during visit

Report was reviewed with House Manager Alma Buclatin and an electronic copy was provided for signature on 05/26/2022.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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