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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202199
Report Date: 01/13/2022
Date Signed: 01/14/2022 10:29:45 AM

Document Has Been Signed on 01/14/2022 10:29 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,
, CA
FACILITY NAME:SCHLOSSER HOMEFACILITY NUMBER:
435202199
ADMINISTRATOR:APRIL MAIMONFACILITY TYPE:
735
ADDRESS:3314 LYNN OAKS DR.TELEPHONE:
(408) 982-3103
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 6CENSUS: 5DATE:
01/13/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:April MaimonTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via Zoom platform with April Maimon Administrator and Sarah Yip Licensing Program Manager to provide technical assistance to prevent and mitigate the spread of COVID 19 in the facility. LPA conducted a virtual tour of the facility.

During today's TA-Visit, recommendations were made to as follows:

1. Maintain paper towels in bathrooms and kitchen sink area.
2. Revised Sign in Symptom Screen Questionnaire
3. Conduct COVID 19 Screen of residents upon return from outings
4. Utilize covered trash containers inside and outside isolation rooms
5. Review OSHA Guidelines on N95 Fit Testing

Report reviewed with April Maimon and a copy emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE:
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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