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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202117
Report Date: 11/21/2022
Date Signed: 11/21/2022 01:04:19 PM

Document Has Been Signed on 11/21/2022 01:04 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:SILVER STAR RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202117
ADMINISTRATOR:FE.O.PUNZALANFACILITY TYPE:
735
ADDRESS:5130 SAN FELIPE RD.TELEPHONE:
(408) 270-6005
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 0DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:TIME COMPLETED:
01:10 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 Administrator Fe Punzalan and Designated Administrator, Mark Arvin Agustin.

During visit, LPA toured the facility to include the living room, kitchen, resident rooms, laundry room, bathrooms, and backyard.

No residents observed on-site. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility. All staff observed wearing a face mask.

Facility has a designated entry point for symptom screening and temperature check for all visitors and staff. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplies with hygiene products, paper supplies, and hand washing sign. LPA observed facility's Personal Protective Equipment (PPE) supplies and trash can with lid. Resident's temperature and symptoms are monitored and documented daily. LPA observed resident's emergency contact information binder. Staff are trained on infection control and have been N95 fit tested. LPA reviewed facility's procedures to isolation, testing, reporting requirements, and visitation. The following posters observed to include symptoms of COVID, hand washing, face mask required, feeling sick, and cover your cough.

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

This report was reviewed with Fe Punzalan and Mark Arvin Agustin and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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