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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202571
Report Date: 08/03/2022
Date Signed: 08/03/2022 03:00:56 PM


Document Has Been Signed on 08/03/2022 03:00 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:BELLEROSE SENIOR LIVINGFACILITY NUMBER:
435202571
ADMINISTRATOR:LORI CORRALFACILITY TYPE:
740
ADDRESS:100 BELLEROSETELEPHONE:
(888) 324-6520
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:26CENSUS: 22DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Lori CorralTIME COMPLETED:
03:10 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) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Lori Corral.

During visit, LPA toured the facility to include the hallways, resident rooms, activity room, kitchen, shower room, laundry room, bathrooms, and storage. Exit areas were observed free and clear of obstruction. All staff observed wearing a face covering.

Facility's temperature was observed at 74 degrees Fahrenheit. Fire extinguishers were serviced in August 2021. LPA observed at least 7 days worth of non-perishable foods and 2 days worth of perishables foods. LPA advised to date all pre-made food in the freezer.

Facility has a central entry point to include symptom screening and temperature check for all visitors. Staff symptom screening log was observed and LPA advised to be consistent with symptom screening and temperature check prior to starting their shift. Hand sanitizer was made available throughout the facility. Bathrooms supplied with paper supplies, hygiene products, and hand washing sign. LPA observed the facility's PPE supplies and PPE cart. Facility staff cleans and disinfects multiple times daily and as needed. Staff were trained on infection control on 06/13/2022. All staff are N95 fit tested.

The following signs observed to include hand washing, visitation guidelines, required mask, and symptoms of COVID.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Lori Corral and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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 3