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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202392
Report Date: 02/16/2021
Date Signed: 02/22/2021 03:38:29 PM

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:EVONNE'S RESIDENTIAL CARE HOME #1FACILITY NUMBER:
435202392
ADMINISTRATOR:PHILOMENA AGBONTAENFACILITY TYPE:
740
ADDRESS:2719 PENITENCIA CREEK RD.TELEPHONE:
(408) 661-5746
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 6DATE:
02/16/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Phelomina AgbontaenTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Grace Davis conducted a Technical Assistance tele-visit via ZOOM. The purpose of this visit is to provide assistance regarding Covid-19 control and mitigation plan. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with Administrator (ADM) Phelomina Agbontaen also present is HFEN nurse Angela Brand.

2 of 6 Residents have been tested covid positive as a result of a mass testing on 02/10/2021. Santa Clara Public Health are aware of COVID-19 cases in the facility

During today's virtual inspection, the facility has signage of COVID-19 in the main door. The screening station have thermometer, hand sanitizer, gloves and disinfectant wipes. The facility has common bathroom with signage, hand soap and garbage bin.

HFEN Nurse Recommendation:
1. Ensure that Covid-19 questionnaire signs and symptoms are review and answer at the screening station.
2. Paper towel with spindle should be provided at the bathroom.
3. Proper hand washing poster need to be posted at the side cabinet closed to kitchen sink.
4. Donning and doffing signage and precaution signs should be posted near rooms of covid positive residents.

No deficiencies observed during this visit. Exit Interview conducted with ADM. A copy of this report is e-mailed to the facility for signature.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace DavisTELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
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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