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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202529
Report Date: 07/21/2021
Date Signed: 07/21/2021 04:53:29 PM

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:MOSELLE CARE HOMEFACILITY NUMBER:
435202529
ADMINISTRATOR:MOHASSEL, LORIFACILITY TYPE:
740
ADDRESS:6797 MOSELLE DRIVETELEPHONE:
(408) 960-6279
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY:6CENSUS: 5DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Zenebesh GhebresellasieTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with licensee, Zenebesh Ghebresellasie.

At 9:50 AM, LPA entered the facility through the facility's central entry point and was screened by staff. At 10:00 AM, a tour of the facility was conducted. COVID-19 postings were observed throughout the facility including bathrooms, living room, kitchen and dining room. Residents' bedrooms were inspected and beds were observed equipped with bed sheets, blankets, and pillows. 2 residents were observed watching TV in the living room. 3 residents were observed in their bedrooms. Social distancing was observed among residents. Staff were observed wearing face coverings. Facility room temperature was 74 F degrees during inspection.

Hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable food and at least 1 week's supply on non-perishable food supply was observed in the premises. Personal protective equipment (PPE) and disinfection supplies were available in the premises.

Per licensee, all residents and staff are fully vaccinated against COVID-19. The facility is currently accepting visitors inside the facility following their COVID-19 mitigation procedures. The facility's mitigation plan was received by the Department.

Exit routes were observed clear and unobstructed. The facility is equipped with smoke detectors, fire extinguishers, and a carbon monoxide detector. A current roster of residents with emergency contact information was reviewed. Licensee to submit current LIC 500 Personnel Schedule to CCLD by July 23, 2021.

No deficiencies were cited. Exit interview conducted with licensee and a copy of this report was provided during visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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