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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201646
Report Date: 04/28/2022
Date Signed: 04/28/2022 04:00:29 PM

Document Has Been Signed on 04/28/2022 04:00 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:K & N MANOR, INC.FACILITY NUMBER:
435201646
ADMINISTRATOR:SEDIGH, MALOUFACILITY TYPE:
735
ADDRESS:2420 BRIDLE PATH DRIVETELEPHONE:
(408) 846-0819
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Remedios BoseTIME COMPLETED:
04:00 PM
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) Christine Dolores arrived unannounced to conduct the annual inspection to focus on infection control and met with Administrator, Remedios Bose.

During visit, LPA toured the inside and outside of the facility to include the entrance, living room, dining room, kitchen, resident rooms, bathrooms and backyard. Toxins and sharp objects were observed secured. Passageways are free and clear of obstruction.

Facility has a designated entry point for COVID-19 symptom screening for residents, staff, and visitors. Staff monitor residents temperature and symptoms daily. Bathrooms observed to be supplied with hygiene products, paper supplies, and hand washing signs. LPA observed facility to have a trash can with lid. LPA observed supply of Personal Protective Equipment (PPE). Facility staff clean and disinfect multiple times daily and as needed. The following signs were observed to include visitor guidance, required mask, stop the spread of germs, and COVID-19 prevention. All staff observed to be wearing a face mask. LPA reviewed facility's policies and procedures to isolation and infection control training.

LPA informed Administrator to submit Infection Control Plan to CCLD by 06/30/2022 and review PIN 22-13-ASC.

No deficiencies issued per the California Code of Regulations, Title 22.

This report was reviewed with Administrator and a copy of this report will be emailed due to printer error.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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