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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202429
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:42:10 PM

Document Has Been Signed on 04/28/2022 03:42 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:A. & T. CARE HOME #3FACILITY NUMBER:
435202429
ADMINISTRATOR:TRAM N. TRUONGFACILITY TYPE:
735
ADDRESS:2495 DASHWOOD AVENUETELEPHONE:
(408) 622-4240
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Edoviges At-AtTIME COMPLETED:
03:45 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 Edoviges At-AT Direct Service Provider (DSP).

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 dining room.

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. Covered trash containers observed in the bathrooms and a foot operated garbage can in the kitchen. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included COVID 19 Screening Symptoms, Please Wear a Mask, Wash Your Hands, Social Distancing, Germs, Droplet Precautions and Cough Etiquette.

No citations were issued per the California Code of Regulations Title 22.

LPA reviewed report with Edoviges At-AT Direct Service Provider (DSP) and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
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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