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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201311
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:30:07 PM

Document Has Been Signed on 07/07/2022 02:30 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ROSSMORE A.R.F. HOMEFACILITY NUMBER:
435201311
ADMINISTRATOR:HELEN V. CARRANZAFACILITY TYPE:
735
ADDRESS:2955 ROSSMORE LANETELEPHONE:
(408) 531-9487
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ernie ManaoisTIME COMPLETED:
02:33 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 07/07/2022 at 01:00pm. Caregiver on site Madelinda Picache (CG) called Administrator Ernie Manaois (Admin) and requested he come to facility. LPA embarked on tour with CG.

LPA toured the facility, including front hallway, kitchen, living room, office, all bedrooms, all bathrooms, dining room, back and side patios, and laundry room. Upon entrance to facility, LPA was screened for symptoms, but temperature was not taken and symptom screening was not recorded. LPA reminded Admin to create a symptom screening questionnaire to be filled out by all visitors and returning residents upon entry into the facility.

All staff observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated. Facility noted to have a 30 day supply of masks, N95s gloves, face shields, and gowns. Admin stated that sole caregiver present had not completed fit testing yet. No prohibited items noted in resident rooms. 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 have been inspected in January of 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors were tested and observed to be operational. Hand washing signs were not observed in the facility bathrooms. Water temperature observed to be 105.3 *F in facility bathroom. Facility temperature observed to be 75*F. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. Advisory notes issued. This report was reviewed with facility administrator Ernie Manaois, and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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