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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202462
Report Date: 11/30/2021
Date Signed: 12/08/2021 10:41:18 AM

Document Has Been Signed on 12/08/2021 10:41 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PEARSON'S CARE HOME #2FACILITY NUMBER:
435202462
ADMINISTRATOR:LOUELLA D. MANZANOFACILITY TYPE:
735
ADDRESS:4140 LOGANBERRY DRIVETELEPHONE:
(408) 300-1467
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LOUELLA MANZANOTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection and met with Administrator Louella Manzano and Assistant Administrator Ramil Manzano.

During visit, LPA toured the facility inside and outside to include dining room, living room, kitchen, laundry room, resident rooms, bathrooms, garage, and backyard. Fire exits were free and clear of obstruction. Medications were secured in a locked cabinet. All staff and residents are fully vaccinated.

LPA observed a central entry point and hand sanitizer for all visitors and staff. All staff were observed wearing a face mask. The following signs were posted to include: symptoms of COVID, visitor policy, feeling ill, and hand washing. LPA observed the bathroom to have paper supplies and soap available for staff, residents, and visitors. Trash can was observed covered with lid. Facility disinfect and sanitize high touch surfaces daily and as needed. LPA reviewed facility's procedures to include isolation, screening, training, and PPE supplies.

LPA obtained a copy of facility's LIC-500, LIC-610D, and current Administrator Certificate. The Department will provide PPE supplies and COVID-19 resources.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory Notes Provided.

This report was reviewed with Administrator Louella Manzano and Assistant Administrator Ramil Manzano. A copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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