<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202561
Report Date: 07/26/2022
Date Signed: 07/26/2022 04:48:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/26/2022 04:48 PM - It Cannot Be Edited
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:CLAYTON CARE HOMEFACILITY NUMBER:
435202561
ADMINISTRATOR:BROWNELL, BRIANFACILITY TYPE:
735
ADDRESS:1597 CLAYTON ROADTELEPHONE:
(408) 375-1132
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:BRIAN BROWNELLTIME COMPLETED:
02:48 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) .BRIAN BROWNELL Upon arrival, Staff Pulita Tolentino (PT) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at entrance and in the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. ADM stated the facility will post more COVID posters in facility. Living room, office, family room, kitchen, dinning room and three restrooms were inspected. Some trash cans were observed without covers. Some Paper towel were observed without holders. ADM stated the facility will put all the trash cans with covers and put all paper towels with holders in 5 days. Posters of washing hands were observed by the sinks in kitchen and restrooms. Cloth towels were observed in the kitchen. Two single resident bedrooms, two shared resident bedrooms, and laundry area were inspected. One staff live-in rooms were observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 74 degree F, and hot water temperature was at 107 degree F in facility. Five residents and three staff were observed in facility. PPE supplies were observed sufficient.

Fire extinguisher was serviced on 4/12/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with booster. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1