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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202485
Report Date: 12/27/2022
Date Signed: 12/27/2022 02:20:16 PM


Document Has Been Signed on 12/27/2022 02:20 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:COUNTRY STYLE LIVINGFACILITY NUMBER:
435202485
ADMINISTRATOR:NORA DENNISFACILITY TYPE:
740
ADDRESS:2231 SUTTER AVENUETELEPHONE:
(408) 260-2844
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:6CENSUS: 3DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Licensee/Administrator Nora DennisTIME COMPLETED:
02:30 PM
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On 12/27/2022 at 1:20pm, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual required inspection and met with Licensee/Administrator (ADM), Nora Dennis.

LPA Rai observed 3 residents in their room taking a nap. Per ADM, 1 resident is under Hospice Care.

During visit, LPA Rai toured the facility to include the family room, dining room, 5 bedrooms, 2 bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff observed wearing a face covering.

Facility has a designated entry point for sign-in, symptom screening, and temperature check for all visitors and staff. Hand sanitizer made available at entry and throughout the facility. Visitation guidelines posted at the entrance. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. LPA Rai observed facility's Personal Protective Equipment (PPE) supplies. Facility has procedures to isolation and testing for COVID-19. Staff are trained on infection control. Staff are N95 fit tested. Facility staff clean and disinfect multiple times daily and as needed. The following posters observed to include wash your hands and symptoms of COVID-19.

LPA Rai requested the following documents to update facility file: Liability Insurance, LIC 500 Personnel Report, LIC 9020 Register of Facility Clients/Residents, RCFE Administration Certification, and First Aid Certification. LPA Rai obtained the documents during the visit.

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

This report was reviewed with Licensee/Administrator, Nora Dennis and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
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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