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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202510
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:08:10 AM

Document Has Been Signed on 12/15/2022 11:08 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:FRIENDS OF CHILDREN WITH SPECIAL NEEDSFACILITY NUMBER:
435202510
ADMINISTRATOR:AI-CHING YEHFACILITY TYPE:
775
ADDRESS:1029 SOUTH BASCOM AVENUETELEPHONE:
(510) 739-6900
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 90CENSUS: 39DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Vivian ChungTIME COMPLETED:
11:10 AM
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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 Director, Vivian Chung.

During visit, LPA toured the facility to include the activity rooms, kitchen, bathrooms, and exterior. All fire exit routes were free and clear of obstruction. Toxins and sharp objects observed secured. Clients and staff observed wearing a face mask.

Facility has a designated entry point to include sign-in, symptom screening, and temperature check for all clients, staff, and visitors. LPA recommended facility to post a sign of all the symptoms of COVID-19 at the entrance. Hand sanitizer made available at entry and throughout the facility. Visitor policy posted at the entrance. Facility has procedures to testing clients and staff twice a week to prevent the spread of COVID-19. Bathrooms supplied with paper supplies, hygiene products, and hand washing sign. LPA observed facility's Personal Protective Equipment (PPE) supplies. Facility has a designated isolation room. LPA recommended facility to ensure the isolation room is ready to be used by placing appropriate posters, PPE supplies, and a lidded trash bin. Facility staff clean and disinfect multiple times daily and as needed. Facility staff has been provided training on infection control. Staff are N95 fit tested. The following posters observed throughout the facility to include but not limited to mask required, cover your cough and sneeze, and hand washing.

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

This report was reviewed with Director, Vivian Chung and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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