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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202529
Report Date: 07/28/2022
Date Signed: 07/28/2022 10:34:50 AM


Document Has Been Signed on 07/28/2022 10:34 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: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: 3DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:ZENEBESH GHEBRESELLASIETIME COMPLETED:
10:45 AM
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On 07/28/2022, Licensing Program Analyst (LPA) Mandeep Kaur conducted an annual inspection and met with licensee, Zenebesh Ghebresellasie.

LPA entered the facility through the facility's central entry point and was screened by staff, Lito Celeste. LPA conducted the tour of the facility. Hand washing signs were observed throughout the facility. Living room, Kitchen and dining area was observed. Residents' bedrooms were inspected and beds were observed equipped with bed sheets, blankets, and pillows.

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

Staff were observed wearing face masks.

Medications are stored in a locked cabinet in the kitchen.

LPA toured the facility inside and out. Sharp objects, toxins, cleaning supplies are secured.

Exit routes were observed clear and unobstructed. The facility is equipped with smoke detectors, fire extinguishers, and a carbon monoxide detector.

No citations were issued per the California Code of Regulations Title 22. Report was reviewed with licensee and a copy of this report was provided during the visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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