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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201229
Report Date: 03/29/2022
Date Signed: 03/29/2022 01:44:44 PM


Document Has Been Signed on 03/29/2022 01:44 PM - 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:LOVELY CARE HOMEFACILITY NUMBER:
435201229
ADMINISTRATOR:ELIZA DAQUIOAGFACILITY TYPE:
740
ADDRESS:3640 HEATHCOT COURTTELEPHONE:
(408) 531-9515
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 5DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Eliza DaquioagTIME COMPLETED:
01:45 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 03/29/2022 at 12:10pm. LPA met with facility Administrator Eliza Daquioag (Admin).

LPA toured the facility, including living room, kitchen, dining room, laundry room, 7 bedrooms, 4 bathrooms, back yard, and back room. Two staff members observed to not be wearing masks upon entry into the facility. All other staff were masked. Admin confirmed that all staff and residents have been vaccinated and boosted.

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 extinguisher observed to be inspected in January 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors tested and observed to be operational.

Facility observed to have designated entry point. Staff took LPA's temperature and but did not screen for symptoms. 30 day supply of PPE was observed. Hand washing signs were observed in facility bathrooms. Water temperature observed to be 120 *F in 2 bathrooms. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with Administrator Eliza Daquioag and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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