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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201644
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:38:56 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/19/2022 03:38 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:DENNIS'S RESIDENTIAL CARE FACILITYFACILITY NUMBER:
435201644
ADMINISTRATOR:DENNIS DONNELLEYFACILITY TYPE:
735
ADDRESS:4195 RIVOIR DRIVETELEPHONE:
(408) 265-3585
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:DENNIS DONNELLEYTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) DENNIS DONNELLEY..Upon arrival, ADM took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. 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 at the main entrance. Living room, family room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towels were observed with holders. No posters of washing hands for 20 seconds were observed by the sinks of kitchen and restrooms. ADM stated the facility will put the posters of washing hands for 20 seconds by the sinks in 3 days. Cloth towels were observed in kitchen. ADM stated ADM will put more paper towels with holders in kitchen. Three resident bedrooms, and laundry room were inspected. One staff live-in room was observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. ADM stated ADM is planing to relocate the medication closet, knives closet, and cleaning product closet. Room temperature was at 79 degree F, and hot water temperature was at 106 degree F in facility. 4 residents and 1 staff were observed in facility.

Fire extinguisher was serviced on 08/14/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with boosters. The facility already submitted LIC9282, Infection Control Plan to CCL office. No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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