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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202271
Report Date: 01/06/2023
Date Signed: 01/06/2023 04:03:00 PM


Document Has Been Signed on 01/06/2023 04:03 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:NOOR ACTIVE LIVINGFACILITY NUMBER:
435202271
ADMINISTRATOR:NAZILA SAFARIFACILITY TYPE:
740
ADDRESS:1818 SCOTT BLVD.TELEPHONE:
(408) 380-4036
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:32CENSUS: 10DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administration Nazila SafariTIME COMPLETED:
04:10 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
On 1/6/2023 @ 3:00pm, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection focusing on infection control. LPA met with Administration Nazila Safari.

During visit, LPA Rai toured the facility to include the lobby, dining room. lounge, 16 resident rooms, 17 bathrooms, kitchen and 3 offices. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Medication stored in a locked room.

Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect twice daily and as often as needed. Bathrooms supplied with hygiene products and hand washing sign. LPA observed a sufficient amount of Personal Protective Equipment (PPE).

The following posters observed to include wash your hands, symptoms of COVID-19, and importance of wearing a mask.

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

This report was reviewed with Administration Nazila Safari and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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