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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202469
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:56:34 PM

Document Has Been Signed on 10/25/2022 04:56 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: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: 6DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:DAISY ESTOESTATIME COMPLETED:
05:00 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, Daisy Estoesta.

During visit, LPA toured the facility with staff to include the living room, kitchen, resident rooms, bathroom, garage, and backyard. Fire exit routes were free and clear of obstruction.

Facility has a designated entry point for symptom screening and temperature check for all visitors. LPA recommended facility to document staff's symptom screening questionnaire and temperature check daily. Visitor guideline not observed posted at the entry. Bathrooms supplied with hand washing sign, hygiene products, and paper supplies. LPA reviewed facility's infection control plans. Facility staff clean and disinfect multiple times daily and as needed. Staff are not N95 fit tested. Resident's temperatures are checked twice daily. LPA reviewed facility's procedures to isolation and visitation. LPA advised facility to conduct infection control training for all staff. The following posters observed to include symptoms of COVID and how to manage respiratory symptoms.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Daisy Estoesta and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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