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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202368
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:09:25 PM


Document Has Been Signed on 05/10/2022 05:09 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,
, CA



FACILITY NAME:CARMONT HOMEFACILITY NUMBER:
435202368
ADMINISTRATOR:RIZALDY CARREONFACILITY TYPE:
740
ADDRESS:1636 EDSEL DRIVETELEPHONE:
(408) 569-9236
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:6CENSUS: 4DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Benjie BaluyotTIME COMPLETED:
01:45 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 Benjie Baluyot Lead Caregiver.

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 observed to have designated entry point for COVID 19 symptom screening. 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 Visitation Policy, Please Wear a Mask, Temperatures Will be Checked, Sanitize Your Hands, Report to Staff Symptoms of Respiratory Distress, In an Emergency Call 911 and Social Distancing.

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 Benjie Baluyot Lead Caregiver and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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