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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202457
Report Date: 12/16/2022
Date Signed: 12/16/2022 12:23:19 PM


Document Has Been Signed on 12/16/2022 12:23 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:SERENITY OF SILICON VALLEYFACILITY NUMBER:
435202457
ADMINISTRATOR:TRINH, THUC OANH NGUYENFACILITY TYPE:
740
ADDRESS:781 TERRAZZO DRIVETELEPHONE:
(408) 224-6225
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 5DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Rita GarciaTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Rita Garcia.

During visit, LPA toured the facility to include the kitchen, dining room, living room, bedrooms, bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff observed wearing a face mask. All staff were fingerprint cleared and associated to the facility.

Facility has a designated entry point for sign-in, symptom screening, and temperature check. Hand sanitizer and face masks made available at entry. LPA recommended facility to post their visitation policy and procedures at the main entrance. Bathrooms supplied with hygiene products and paper supplies. Administrator was informed to place a hand washing sign in the bathroom. LPA observed the facility's Personal Protective Equipment (PPE) supplies to not be complete. The Department will supply facility with additional PPE supplies. LPA reviewed the facility's procedures to isolation. LPA recommended facility staff to document the resident's temperature and symptoms at least three times a day, and as often as needed. Facility staff clean and disinfect multiple times daily and as needed. LPA observed facility staff to be trained on infection control. Staff are not N95 fit tested and Administrator was provided verbal resources on where to conduct N95 fit testing.

LPA observed the facility's perishable and non-perishable food supplies to not be correctly labeled. LPA advised the Administrator and the Administrator stated understanding. See LIC-9102.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Administrator, Rita Garcia and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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