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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202411
Report Date: 02/17/2023
Date Signed: 02/17/2023 10:53:23 AM

Document Has Been Signed on 02/17/2023 10:53 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:KINGMAN CARE HOME LLCFACILITY NUMBER:
435202411
ADMINISTRATOR:ANTHONY CASIMFACILITY TYPE:
740
ADDRESS:1426 KINGMAN AVENUETELEPHONE:
(408) 945-9197
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 6DATE:
02/17/2023
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elvira Casim and Avelina PascuaTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled virtual technical assistance visit via Facetime. The meeting was conducted with Licensee, Elvira Casim, House Manager, Avelina Pascua, Program Clinical Consultant (PCC) Anna Guinto, LPA Trang Pham, and Licensing Program Manager, Jackie Jin.

The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

During today's tele-visit, the following recommendations were made to the facility by PCC:

1. Develop a staffing contingency plan
2. Provide staff with N95 fit testing per CalOSHA requirements
3. Post a required mask and symptoms of COVID-19 poster at the front door
4. Label homemade chemicals (Bleach + Water) in the spray bottle. Remind staff the homemade solution is only good for 24 hours
5. Use a fresh set of PPE supplies when assisting COVID-19 positive residents with laundry
6. Post an "isolation room in use" poster outside the isolation room, when applicable
7. Post a donning and doffing poster inside and outside of the isolation room
8. Gowns should be disposed after one use and shall not be re-used
9. Face shields and N95 masks should be left outside of the isolation room

The Department will provide Licensee with COVID-19 resources and information.
No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed on the telephone with Licensee, Elvira Casim and a copy of the report will be emailed for signature.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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