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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202241
Report Date: 07/22/2022
Date Signed: 07/22/2022 04:11:58 PM

Document Has Been Signed on 07/22/2022 04:11 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:SACRED HAVEN CARE HOME INC.FACILITY NUMBER:
435202241
ADMINISTRATOR:EDNA G. ORIBELLOFACILITY TYPE:
735
ADDRESS:1222 WAGON WAYTELEPHONE:
(408) 848-6205
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 5DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:TIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection to focus on infection control. LPA met with designated Administrator, Alma Buclatin.

During visit, LPA toured the facility to include the dining room, living room, kitchen, resident rooms, bathrooms, and backyard. All fire exit routes are free and clear of obstruction.

The facility has a designated central entry point to include symptom screening and temperature check for all visitors. LPA advised to create a symptom screening log for all staff and residents. Visitor policy and required mask posted at the entrance. Hand sanitizer made available throughout the facility. Bathroom supplied with hygiene products, paper supplies, and hand washing sign. Facility staff clean and disinfects multiple times daily and as needed. Facility staff monitor the resident's temperature and symptoms daily. LPA observed facility's Personal Protective Equipment (PPE) supplies. LPA reviewed facility's policies and procedures to isolation, infection control training, and visitation. Staff are N95 fit tested.

The following signs observed to include symptoms of COVID, cough etiquette, droplet precaution, feeling ill, and donning and doffing PPE.

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

This report was reviewed with designated Administrator, Alma Buclatin and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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