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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202469
Report Date: 10/25/2021
Date Signed: 10/25/2021 04:42:11 PM

Document Has Been Signed on 10/25/2021 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:DESTA RESIDENTIAL CARE FACILITYFACILITY NUMBER:
435202469
ADMINISTRATOR:DAISY ESTOESTAFACILITY TYPE:
735
ADDRESS:2012 AUTUMNTREE CT.TELEPHONE:
(408) 930-7565
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 5DATE:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Daisy Estoresta, ADMTIME COMPLETED:
10:15 AM
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At 9:00AM, licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Daisy Estoresta.

Upon arrival, caregiver Sonia Tapispisan (ST) took LPA's body temperature, asked the infection control screening questionnaires, and checked LPA in the visitor log book. LPA observed the COVID related posters in the facility. LPA observed two staff live-in rooms in facility. Three resident single rooms, one resident shared room, two restrooms, living room, dinning area and kitchen were observed in facility. The trash cans were observed all with covers. Garage was inspected.

LPA checked PPE supplies, PPE supplies were observed sufficient. Cleaning products and detergents were observed locked. Medication closet was observed locked. knives closet was observed unlocked. ADM fixed it immediately. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Cloth towel was observed in the kitchen. ADM stated the cloth towel will be removed. Room temperature was 74 degree F, and hot water temperature was 110 degree F.

LPA discussed LIC808 with ADM. ADM stated all the residents and staff are fully vaccinated. ADM stated the facility already scheduled the booster shots for all residents and staff in two weeks.

No deficiency or allegation was issued today. Exit interview conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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