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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201082
Report Date: 10/19/2021
Date Signed: 10/20/2021 08:07:40 AM

Document Has Been Signed on 10/20/2021 08:07 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:A & T CARE HOMEFACILITY NUMBER:
435201082
ADMINISTRATOR:NGO, ALLISONFACILITY TYPE:
735
ADDRESS:1768 VIA FLORES COURTTELEPHONE:
(408) 956-1484
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Flordeliza RavaneraTIME COMPLETED:
12:01 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/19/2021 at 10:38am. LPA met with facility lead staff member Flordeliza Ravanera (S1).

LPA toured the facility, including living room, kitchen, garage, family room, bonus room, 3 client bedrooms, 1 staff bedroom, 2 bathrooms, and back yard. All staff members observed to be wearing masks. S1 confirmed that all staff and residents have been vaccinated and that clients received their booster shot.

Facility Mitigation plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in August of 2021. Facility fire alarms tested and observed to be in working order.

Facility observed to have designated entry point. Staff took LPA's temperature, but did not screen for symptoms. 30 day supply of most PPE observed, however, facility did not have a supply of N95s. S1 stated that they would speak with facility administrator in regards to purchasing more N95s for the facility immediately. All restrooms stocked with paper towels. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms.

No deficiencies cited during today's visit. This report was reviewed with Lead Staff Member Flordeliza Ravanera and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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