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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201493
Report Date: 05/13/2021
Date Signed: 05/28/2021 01:59:27 PM

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 HEAVENLY CARE HOMEFACILITY NUMBER:
435201493
ADMINISTRATOR:FONTANILLA, DIANAFACILITY TYPE:
740
ADDRESS:259 CHECKERS DRIVETELEPHONE:
(408) 926-3285
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:6CENSUS: 3DATE:
05/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Diane FontanillaTIME COMPLETED:
04:15 PM
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On 05/13/2021 at 3:00 pm, Licensing Program Analysts (LPAs) Anna Bui, Yatfai (Eric) Ng, and Ryker Heberle conducted an infection control inspection. LPAs met with Administrator Diana Fontanilla.

LPAs toured the facility beginning with the main entrance. The entrance had a thermometer, hand sanitizer, and sign-in log to document temperature. No screening questions were asked or documented. LPAs recommended screening questions to be asked and documented. Universal precautions, COVID-19 protocols, and social distancing guidelines were posted throughout the facility. Restrooms had hand soap and paper towels readily available. Restroom had a trash can with a lid, but not a foot pedal. LPAs recommended a step trash can with a lid for shared bathrooms. Hand washing sign was posted at hand washing stations. PPE was available for staff, visitors, and residents.

Residents were not observed wearing a mask. LPAs recommended Administrator to encourage residents to wear mask when in common areas or shared spaces. Dining rooms were observed with chairs not spaced at least six feet apart. LPAs recommended residents to sit at least six feet apart or have staggered meals.

Technical Assistance was provided during this visit, see LIC 9102.

Exit interview was conducted and this report was reviewed with Administrator Diane Fontanilla, and a copy of this report was left with Administrator Diane Fontanilla.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna BuiTELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
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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