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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201034
Report Date: 08/20/2021
Date Signed: 08/21/2021 09:15:37 AM

Document Has Been Signed on 08/21/2021 09:15 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ESR MANORFACILITY NUMBER:
435201034
ADMINISTRATOR:REYES, ELIZABETHFACILITY TYPE:
735
ADDRESS:602 NOVAK DRIVETELEPHONE:
(408) 926-0859
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 4DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Senen Semana, Lead staffTIME COMPLETED:
04:41 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annually inspection and met with Staff Lead .Senen Semana (SS)..

Upon arrival at the facility main entrance, staff Emerencian Rabara (ER) took LPA's body temperature, asked LPA the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility with SS. There are 3 resident rooms in the facility. LPA observed 4 residents (R1 - R4) in the bedrooms, living room, and family room. LPA observed another staff Jhed Paguio (JP) in facility. COVID-19 posters were observed at the facility. LPA observed the staff wore the masks.

LPA inspected the facility food supplies. The two day perishable food and seven day nonperishable foods are sufficient. LPA observed hand sanitizer were at many places in the facility. LPA observed not all the trash bins in the facility are with covers. SS stated the facility will change all the trash cans to be with covers. LPA observed the beds in one bedroom is not 6 feet apart. SS stated the facility will make the beds 6 feet apart. SS stated all the staff and residents are fully vaccinated.

No citation were issued during today's inspection. Exit interview conducted with SS. This report was provided to SS to review and to sign. A copy of this report was emailed to SS.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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