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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201549
Report Date: 02/17/2023
Date Signed: 02/17/2023 12:24:21 PM

Document Has Been Signed on 02/17/2023 12:24 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:CORKTREE HOUSEFACILITY NUMBER:
435201549
ADMINISTRATOR:CAYABYAB, PERLAFACILITY TYPE:
735
ADDRESS:2170 CORKTREE LANETELEPHONE:
(408) 499-3708
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 2DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with caregiver, Gimenia Manuel. Administrator, Perla Cayabyab met LPA at the facility about 30 minutes after arrival.

During visit, LPA toured the facility with caregiver to include the garage, dining room, living room, kitchen, bedrooms, bathroom, and garage. All passageways are free and clear of obstruction. Staff present observed wearing a face mask and are fingerprint cleared and associated to the facility.

Facility has a designated entry point located in the garage for COVID-19 symptom screening and temperature check for all visitors and staff. Hand sanitizer and face masks made available at entry. LPA recommended facility to post the facility's visitation guidelines and COVID-19 posters at the designated entry point, to include but limited to, masks required and symptoms of COVID-19. LPA observed the facility's Personal Protective Equipment (PPE) supplies and PPE cart. Bathroom supplied with hand washing sign, hygiene products, and paper supplies. ADM verbally states the staff are trained on infection control, but facility did not physically have the training record or infection control plan on-site. LPA advised facility to ensure training documents and infection control plan are presentable at the facility. Facility staff are N95 fit tested. Facility clean and disinfect multiple and as often as needed. Facility has procedures to isolation and testing for COVID-19.The following posters observed to include, but not limited to, feeling ill, cough etiquette, symptoms of COVID-19, hand washing, and donning and doffing PPE.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Administrator, Perla Cayabyab and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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