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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200974
Report Date: 03/07/2022
Date Signed: 03/08/2022 08:23:48 AM

Document Has Been Signed on 03/08/2022 08:23 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:CHURCH RCFFACILITY NUMBER:
435200974
ADMINISTRATOR:ZIPAGAN, AZUCENAFACILITY TYPE:
740
ADDRESS:1306 CHURCH AVENUETELEPHONE:
(408) 686-0751
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 6DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Sandy ZipaganTIME COMPLETED:
02:05 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 Azucena (Sandy) Zipagan Administrator.

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 room.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products and a covered trash can. Hand Washing signs posted in the bathrooms and in the kitchen. Hand sanitizer available to visitors and residents. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Symptoms of COVID 19, It's a Two Way Street, Please Wear a Mask, Visiting Options, Guidelines for Health and Safe Life, How Can I Protect Myself, Universal Precautions and Social Distancing.

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

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

LPA reviewed report with Sandy Zipagan and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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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