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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202081
Report Date: 02/14/2023
Date Signed: 02/14/2023 01:59:37 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/14/2023 01:59 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:CALIFORNIA RESIDENTIAL FACILITYFACILITY NUMBER:
435202081
ADMINISTRATOR:SASHI LATA KUMARFACILITY TYPE:
735
ADDRESS:3781 POLTON PLACE WAYTELEPHONE:
(408) 390-6172
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
02/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Sashi KumarTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with Administrator (ADM) Sashi Kumar. Upon arrival, ADM took LPA body temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. LPA observed 6 residents and 2 staff in facility.

LPA toured the facility inside and out with ADM. No COVID posters were observed on the main entrance door. ADM stated the facility will put the COVID posters on the main entrance door within 5 days. LPA inspected living room, family room, kitchen, dinning area, and laundry room. Medication closet, knives closet and cleaning product closet were observed locked. There are 3 bedrooms for residents, and one staff live-in room in facility. 3 bathrooms are in facility. Paper towels were observed with holders, Trash cans were observed without covers in 3 restrooms. ADM stated the facility will replace the trash cans with trash cans with covers within 5 days. Posters of washing hands for 20 seconds were not observed by the sinks in kitchen and restrooms. ADM stated the facility will put posters of washing hands for 20 seconds by the sinks in kitchen and restrooms. Cloth towels were observed in kitchen and restrooms. Room temperature was observed at 72 degree F, and hot water temperature was observed at 109 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient. PPE supplies were observed sufficient.

The facility is equipped with fire alarm system, smoke and carbon monoxide detectors. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 11/30/2022. LPA inspected the backyard, there was no obstruction to block the walkway. ADM stated all staff and residents are fully vaccinated and done with booster. ADM stated the facility already submitted the Infection Control. Plan to CCL office.

No citation noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2023
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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