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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202302
Report Date: 04/28/2022
Date Signed: 04/29/2022 08:56:14 AM


Document Has Been Signed on 04/29/2022 08:56 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:NORWOOD CREEK RESIDENTIAL FACILITY LLCFACILITY NUMBER:
435202302
ADMINISTRATOR:VIOLETA S. DUMOFACILITY TYPE:
740
ADDRESS:3267 PADILLA WAYTELEPHONE:
(408) 238-6992
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Violeta DumoTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Violeta Dumo Administrator.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the kitchen. Facility has designated the master bedroom as an isolation room and has a foot operated trash container available and ready for use.

Facility observed to have designated entry point for COVID 19 symptom screening. Residents and staff are screened daily and a log is maintained. Hand sanitizer available to visitors and residents. Bathrooms observed to be supplied with hygiene products. Hand Washing signs posted in the bathrooms and in the kitchen near the sinks. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Please Wear a Mask, COVID Screening Symptoms, Social Distancing, and Limit the Spread of Germs.

LPA reviewed the facility policies and procedures to include screening, visitation, testing, masking, isolation and disinfecting.

No citations were issued per the California Code of Regulations Title 22.

LPA reviewed report with Violeta Dumo Administrator and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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