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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202011
Report Date: 08/16/2021
Date Signed: 08/17/2021 08:18:15 AM

Document Has Been Signed on 08/17/2021 08:18 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HEARTS AND MINDS ACTIVITY CENTERFACILITY NUMBER:
435202011
ADMINISTRATOR:MARIA NICOLACOUDISFACILITY TYPE:
775
ADDRESS:2380 ENBORG LANETELEPHONE:
(408) 279-7515
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 90CENSUS: 29DATE:
08/16/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Barbara DeLashTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Administrator Designee, Barbara DeLash and Administrator, Maria Nicolacoudis. During visit, LPA conducted a Facetime tour of the facility with Program Clinical Coordinator (PCC) Helen Shi and Licensing Program Manager (LPM) Jackie Jin. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA toured the facility inside and out to include: central entry-point, bathrooms, 3 activity rooms, and outdoor area. LPA observed posters including social distancing and required face masks posted inside and outside of the facility.

During today's tele-visit, the following recommendations were made to the facility by PCC, Helen Shi.

1. Place hand-washing posters in all bathrooms
2. Place donning and doffing PPE sign outside of the isolation room for a reminder of proper PPE usage

Administrator Barbara DeLash emailed LPA Christine Dolores pictures of hand-washing posters posted in all bathrooms and Donning and Doffing PPE sign outside isolation room.

No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via tele-visit with Administrator, Maria Nicolacoudis. A copy of the report will be emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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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