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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202205
Report Date: 09/21/2022
Date Signed: 09/21/2022 12:04:56 PM

Document Has Been Signed on 09/21/2022 12:04 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:SANTOS CARE HOMEFACILITY NUMBER:
435202205
ADMINISTRATOR:MICHELLE S. SANTOSFACILITY TYPE:
735
ADDRESS:1706 MT. RANIER AVE.TELEPHONE:
(408) 469-7154
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 6CENSUS: 6DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Michelle SantosTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Simi Rai arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPAs met with Administrator, Michelle Santos.

During visit, LPAs toured the facility to include the living room, resident rooms, bathrooms, kitchen, garage, and backyard. All fire exit routes were free and clear of obstruction. Toxins and sharp objects observed secured. Facility temperature maintained at 72 degrees Fahrenheit.

All staff are fingerprint cleared and associated to the facility. Staff observed to be wearing a face mask. Staff are N95 fit tested.

Facility has a designated entry point for symptom screening and temperature check for all staff and visitors. Visitation policy posted at entry. Hand sanitizer available. Bathrooms supplied with hygiene products and paper supplies. LPA Dolores advised to place a 20 second hand washing sign at all sink areas. LPAs observed facility's Personal Protective Equipment (PPE) supplies. Facility staff clean and disinfect multiple times daily and as needed. The following posters observed to include required mask, social distancing, donning and doffing, and symptoms of COVID-19. LPAs reviewed facility procedures to visitation, isolation, testing, monitoring, and infection control training.

Facility's Infection Control Plan for Monkeypox was obtained during visit.

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

This report was reviewed with Michelle Santos and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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