<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201454
Report Date: 11/18/2021
Date Signed: 11/18/2021 03:47:33 PM

Document Has Been Signed on 11/18/2021 03:47 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:CARRANZA 2 A.R.F.FACILITY NUMBER:
435201454
ADMINISTRATOR:HELEN CARRANZAFACILITY TYPE:
735
ADDRESS:4339 MOORPARK AVE.TELEPHONE:
(408) 873-7390
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 12CENSUS: 9DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ernie Manaois, ADMTIME COMPLETED:
10:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with administrator (ADM) Ernie Manaois. ADM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book. COVID posters were observed at main entrance and in the facility. Screening station with masks, hand sanitizer, glove, thermometer, and visitor log book was observed. One staff was observed in facility.

LPA toured the facility inside out with ADM. Family room, dinning room, kitchen, office, and 3 restrooms were inspected. Paper towels were observed with holders. Not all trash cans were with covers. ADM stated the facility will change all the trash cans in 2 days. Washing hands posters by the sinks were observed. There are 4 resident single rooms and 3 resident shared rooms in facility. There are 2 staff live in rooms in facility. The beds in shared were observed 6 feet apart. LPA observed 9 residents in facility. Room temperature was at 70 degree F, and hot water temperature was at 108 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Knives closet, medication closet, and cleaning product closet were observed locked. The facility is equipped with smoke and carbon monoxide detectors.

PPE supplies were observed sufficient. Front yard and backyard were inspected. There was no obstruction to block the walkways. ADM stated all the residents and staff are fully vaccinated.

No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
Romeo Manzano
Chihhsien Chang
DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1