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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202530
Report Date: 09/21/2021
Date Signed: 09/23/2021 03:59:04 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:DOMA CARE HOMEFACILITY NUMBER:
435202530
ADMINISTRATOR:LI, XUANFACILITY TYPE:
740
ADDRESS:489 DOMA DRIVETELEPHONE:
(408) 335-6347
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:6CENSUS: 1DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Xiuzhen FangTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit. LPA met with the Licensee Xiuzhen Fang.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station with hand sanitizer and disposable masks were present at the entrance.

LPA toured the facility. The facility was observed to be in sanitary condition. The Licensee was wearing mask. There were COVID-19 signs and hand sanitizers at the entrance.

LPA inspected 1 restroom for resident. The restroom was observed to be adequately stocked with hand soap. Hand washing sign was present. There was an adequate supply of personal protective equipment in the storage areas.

LPA discussed the infection control, reviewed the current Provider Information Notice PIN 21-40-ASC with Licensee and made suggestions. The resident and all staff were fully vaccinated per Licensee.

No deficiency cited during visit. However, advisory notes were issued.

This report was reviewed with Licensee. A copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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