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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200975
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:48:01 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:KINGSPARK VILLAFACILITY NUMBER:
435200975
ADMINISTRATOR:VALIN, NORMANFACILITY TYPE:
740
ADDRESS:4318 KINGSPARK DRIVETELEPHONE:
(408) 629-5727
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 6DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Norman Valin, ADMTIME COMPLETED:
10:50 AM
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At 9:00AM, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection. Upon arrival, staff Francis Imperial (FI) took LPA's body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with administrator (ADM) Norman Valin. LPA observed COVID posters at main entrance and in facility. Hand sanitizer, masks, gloves, thermometer and visitor log book were observed at the screening station. Living room, kitchen, dinning area, and two bathrooms were inspected. No washing hand poster was observed by the sinks. Not all the trash cans were with covers. ADM stated the facility will fix these two issues in 3 days. There are 3 resident shared rooms at the first floor. The beds in the shared rooms were observed 6 feet apart. There are 3 bedrooms for live-in staff, one restroom and one office at the second floor. 4 staff and 5 residents were observed in facility. No obstruction was observed at the backyard and front yard.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning products closet were observed locked. PPE supplies were observed sufficient. Fire extinguishers were serviced on 07/08/2021. Room temperature was at 70 degree F, and hot water temperature was at 112 degree F. Carbon Monoxide and fire detectors were tested and were working fine.

ADM brought the 6 resident file binders for LPA to review. ADM stated all residents and staff are fully vaccinated and all resident and staff have the booster shots.

Exit interview was conducted with ADM. No deficiency or citation were noted. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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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