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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201156
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:23:36 AM

Document Has Been Signed on 10/21/2022 11:23 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:GLEN ELM CARE HOME, INCFACILITY NUMBER:
435201156
ADMINISTRATOR:YOLANDA GAOIRANFACILITY TYPE:
735
ADDRESS:2487 GLEN ELM WAYTELEPHONE:
(408) 687-6979
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Yolanda GaoiranTIME COMPLETED:
11:26 AM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/12/2021 at 03:23pm. LPA met with facility Administrator Yolanda Gaoiran (Admin).

LPA toured the facility, including living room, kitchen, garage, dining room, laundry room, 3 storage rooms, 3 resident bedrooms, 3 staff bedrooms, 2 staff offices, 2 bathrooms, back patio, and front yard. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility infectious control 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 June of 2022.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be 119.0 *F. 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 Administrator Yolanda Gaoiran and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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