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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202440
Report Date: 09/27/2022
Date Signed: 09/27/2022 04:42:45 PM

Document Has Been Signed on 09/27/2022 04:42 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BLUE RIDGE RCHFACILITY NUMBER:
435202440
ADMINISTRATOR:FREDRICKA SAFARFACILITY TYPE:
735
ADDRESS:4209 BRIARGLEN DRIVETELEPHONE:
(415) 385-8900
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 5DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Fredricka SafarTIME COMPLETED:
04:46 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 09/27/2022. LPA met with facility Administrator Fredricka Safar (Admin).

LPA toured the facility, including living room, garage, 3 bedrooms, 2 bathrooms, kitchen/dining room, back yard, and RV staff quarters. Staff members were observed not to be wearing masks upon LPA arrival. Admin confirmed that all staff and residents have been vaccinated. Facility infectious control plan has been submitted to licensing.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. 30 days worth of PPE was observed.

Facility observed to have designated entry point. Staff took LPA's temperature, but did not screen for symptoms. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. Staff has completed N95 fit testing.

Facility fire extinguishers were to have gauges within acceptable levels. Facility water temperature observed to be 107.6*F. Facility temperature was observed to be 81*F. LPA observed smoke detectors and a carbon monoxide detector, which were tested and confirmed to be operating properly.

No deficiencies cited during today's visit. This report was reviewed with Administrator Fredricka Safar and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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