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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202548
Report Date: 11/07/2020
Date Signed: 11/07/2020 05:44:10 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:MINA'S ELDERLY CARE HOME 2FACILITY NUMBER:
435202548
ADMINISTRATOR:ABBASVAND, MINAFACILITY TYPE:
740
ADDRESS:3668 SYDNEY COURTTELEPHONE:
(408) 649-3628
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:0CENSUS: 6DATE:
11/07/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mina Abbasvand, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jackie Jin and Licensing Program Manager (LPM) Julio Montes conducted an initial COVID-19 positive intake. LPA and LPM met with Mina Abbasvand, Administrator.

During today's initial COVID-19 positive intake Administrator stated COVID positive cases were reported to Administrator's assigned LPA that is no longer with the Adult and Senior Care Program and a voicemail was left for Department of Health. An incident report was also submitted to CCL.

LPA requested Administrator to submit the following: communication report sent to assigned LPA and Department of Health, mitigation plan, staffing schedule for the week, incident submitted to CCL by 11/10/2020.

This report was reviewed with Mina Abbasvand, Administrator and a copy of this report will be emailed to Mina Abbasvand, Administrator on 11/07/2020 for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2020
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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