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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201757
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:54:49 PM

Document Has Been Signed on 05/20/2022 04:54 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:ELEANOR'S GLACIER (2) HOMEFACILITY NUMBER:
435201757
ADMINISTRATOR:BASA, ELEANORFACILITY TYPE:
735
ADDRESS:893 RENTON COURTTELEPHONE:
(408) 224-6224
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 3DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Elsie CasumpangTIME COMPLETED:
02:36 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Elsie Casumpang. Upon arrival, HM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with HM. COVID posters were observed at main entrance and the facility. No screening station at the main entrance, but masks, hand sanitizer, glove, thermometer and visitor log book were observed at living room and dinning area. HM stated the facility will setup a screening station at the man entrance in 3 days. Living room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towel were observed with holders. Three resident bedrooms were inspected. One staff live-in room is in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 106 degree F in facility. One residents was observed in facility.

Fire extinguisher was serviced on 4/29/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Front yard and backyard were inspected. There was no obstruction to block the walkways.

HM stated all the residents and staff are fully vaccinated and done with booster. No citation were noted today. Exit interview was conducted with HM. This report was provided to HM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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