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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202011
Report Date: 12/15/2022
Date Signed: 12/15/2022 12:19:27 PM

Document Has Been Signed on 12/15/2022 12:19 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
CENTRAL COAST CR/RES, 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: 150CENSUS: 45DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Barbra DeLashTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Operations Manager, Barbra DeLash.

During visit, LPA toured the facility to include the activity rooms, kitchen, bathrooms, isolation rooms, medication room, offices, and exterior. All fire exit routes were free and clear of obstruction. Toxins and sharp objects observed secured. Clients and staff observed wearing a face mask.

Facility has a designated entry point for each building to include sign-in, symptom screening, and temperature check. Hand sanitizer made available at entry and throughout the facility. Required mask sign and visitor policy posted at the entrance. Facility test clients and staff once a week to prevent the spread of COVID-19. Bathrooms supplied with paper supplies, hygiene products, and hand washing sign. LPA observed facility's Personal Protective Equipment (PPE) supplies. Facility has an isolation room for each building. Lidded trash bin observed throughout the facility. Facility staff clean and disinfect multiple times daily and as needed. Staff are trained on infection control and are N95 fit tested. The following posters observed to include but not limited to stop and prevent the spread of germs, symptoms of COVID-19, wear your mask, and cover your cough.

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

This report was reviewed with Operations Manager, Barbra DeLash and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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