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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201853
Report Date: 03/07/2022
Date Signed: 04/11/2022 08:43:35 AM

Document Has Been Signed on 04/11/2022 08:43 AM - 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,
, CA
FACILITY NAME:SIERRA HEIGHTS MANORFACILITY NUMBER:
435201853
ADMINISTRATOR:MARIA CECILIA O. CLARIDADFACILITY TYPE:
735
ADDRESS:2975 COHANSEY DRIVETELEPHONE:
(408) 272-7432
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 5DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maria Cecilia ClaridadTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Maria Cecilia Claridad Administrator. Two staff were present assisting residents and cooking dinner of chicken, vegetables and potatoes. Vegetarian meal prepared for one resident.

LPA toured the facility inside and out to include designated Isolation Room with exterior door. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the kitchen. Foot operated trash can observed in the kitchen.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products and hand washing signs posted. Hand sanitizer available to visitors and residents. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Symptoms of COVID 19, Are you feeling Sick, COVID 19 When to Seek Care, COVID Cleaning, and Keep Our Facility Clean.

LPA reviewed the facility policies and procedures to include screening, visitation, masking, isolation and disinfecting,

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

LPA reviewed report with Maria Cecilia Claridad and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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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