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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202005
Report Date: 10/11/2022
Date Signed: 10/11/2022 11:53:14 AM

Document Has Been Signed on 10/11/2022 11:53 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CA NATIONAL MENTOR - CALERO HOMEFACILITY NUMBER:
435202005
ADMINISTRATOR:BEVERLY OLIVEROSFACILITY TYPE:
734
ADDRESS:826 CALERO AVE.TELEPHONE:
(408) 224-4522
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 5CENSUS: 3DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:LILIBETH SALAZARTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual inspection focusing on infection control. LPA met with house manager, Lilibeth Salazar.

During visit, LPA toured the facility to include the living room, kitchen, office space, resident rooms, bathrooms, laundry room, garage, and backyard. All staff observed wearing a face mask. Facility temperature maintained at 71 degrees Fahrenheit.

The facility has a designated entry point for symptom screening and temperature check for all visitors and staff. Hand sanitizer available at entry and throughout the facility. LPA advised to remove the no visitor sign posted at the front door. Bathrooms supplied with hygiene products, hand washing sign, and paper supplies. Trash can with lid observed in every room. LPA observed facility's Personal Protective Equipment (PPE) supplies. Facility staff clean and disinfecting multiple times daily and as needed. Staff are N95 fit tested. Staff are trained in infection control. LPA reviewed facility's procedures to visitation, isolation, reporting, and testing requirements. The following posters observed to include symptoms of COVID, required mask, cover your cough, and contact precaution.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Lilibeth Salazar and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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