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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202393
Report Date: 04/26/2022
Date Signed: 04/27/2022 04:24:54 PM

Document Has Been Signed on 04/27/2022 04:24 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:APOLLO ADULT RESIDENTIAL CAREHOME 1FACILITY NUMBER:
435202393
ADMINISTRATOR:FERMIN DELA CRUZFACILITY TYPE:
735
ADDRESS:2633 APOLLO COURTTELEPHONE:
(408) 622-5357
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Fermin Dela CruzTIME COMPLETED:
02:50 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 Fermin Dela Cruz Administrator. 5 Clients were attending Day Program.

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. Fresh fruit of apples, bananas and oranges were observed 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. Foot operated trash containers observed in the bathrooms and in the kitchen. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Wear a Mask, Stop Wash Your Hands, Visitor Policy, COVID Screening Symptoms, Social Distancing, Are You Feeling Ill, Droplet Precaution and Self-Monitor and Practice.

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 Fermin Dela Cruz Administrator and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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