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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202331
Report Date: 04/28/2022
Date Signed: 04/28/2022 01:58:03 PM

Document Has Been Signed on 04/28/2022 01:58 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SVS GILROY ADULT DAY PROGRAMFACILITY NUMBER:
435202331
ADMINISTRATOR:ALISON NOBLEFACILITY TYPE:
775
ADDRESS:7101 MONTEREY ROADTELEPHONE:
(408) 843-9630
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 60CENSUS: 59DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Maria AguirreTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Personal Plan Facilitator Maria Aguirre. LPA observed clients leaving the day program upon arrival. There are 28 clients participating in in-person program and 31 clients participating virtually. The day program is open for alternative in-person Monday - Friday from 8:30am - 1:00pm.

During visit, LPA toured the facility to include the entrance, activity rooms, restrooms, staff break room, and offices. All exit routes were free and clear of obstruction. All staff and clients observed to be wearing a face mask.

Facility observed to have designated entry point for sign-in for all clients, staff, and visitors. Temperature is taken upon entry. Staff are symptom screening clients prior to entering in the transportation vehicle. Hand sanitizer available upon entry and throughout the facility. Activity rooms are equipped with disinfectant wipes and hand sanitizer. All activity rooms are provided with a maximum capacity and social distancing sign. Bathrooms observed to be supplied with hygiene products, paper supplies, trash can with lid, and hand washing sign. Facility has signs posted in the hallway to encourage clients to walk in one direction and maintain social distancing. LPA observed supply of Personal Protective Equipment (PPE). Facility has an isolation room. LPA reviewed facility's policies and procedures for isolation. Facility clean and disinfect daily and as needed.The following posters were observed to include social distancing, stop the spread of germs, and how to wear a face mask.

LPA informed staff to review PIN 22-13-ASC and to submit Infection Control Plan to CCLD by 06/30/2022.

No citations were issued per the California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Maria Aguirre and a copy of the report will be emailed due to printer error.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
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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