<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202115
Report Date: 10/06/2021
Date Signed: 10/06/2021 04:23:03 PM

Document Has Been Signed on 10/06/2021 04:23 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:FLINTCREST HOUSE IIFACILITY NUMBER:
435202115
ADMINISTRATOR:NILO AMBAGANFACILITY TYPE:
735
ADDRESS:3094 STEVENS LANETELEPHONE:
(408) 528-7734
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Rhodora AvilesTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Rhodora Aviles, DSP.

LPAs toured the facility inside and out to include the entry, bedrooms, bathrooms, kitchen, dining room, living room and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in locked cabinet. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. The following posters were observed to include stop the spread of germs, special visitors, feeling ill, cough etiquette, and hand washing. Hand sanitizer available to residents, staff, and visitors. LPAs observed supply of Personal Protective Equipment (PPE). Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19.

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

LPA reviewed report with Rhodora Aviles, DSP and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1