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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202574
Report Date: 10/01/2020
Date Signed: 10/01/2020 12:41:41 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:CAHALAN VILLAFACILITY NUMBER:
435202574
ADMINISTRATOR:JUANILLO, VIVIELYNFACILITY TYPE:
740
ADDRESS:5903 CAHALAN AVENUETELEPHONE:
(408) 578-8068
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 4DATE:
10/01/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vivielyn JuanilloTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Gladys Kuizon and Grace Davis conducted a Case Management tele-visit today and met with licensee/administrator Vivielyn Juanillo and Michelle Benitez. Due to COVID-19 preventive measures, physical visits have been suspended.

The purpose of this case management was to provide technical assistance to the facility regarding COVID-19 guidelines as outlined in Community Care Licensing Division (CCLD) Provider Information Notice (PIN) 20-23-ASC.

LPAs toured the facility including residents' bedrooms and bathroom. The facility's screening in and out procedures were reviewed.

The facility was observed to have required postings in conspicuous locations including the main entrance and hand-washing stations. The facility has sufficient supply disinfectants. Personal protective equipment and supplies were observed in the premises. Facility is requesting additional masks, hand sanitizers, gloves and face shields.

LPAs provided additional COVID-19 postings and shared additional resources to facility regarding COVID-19 including the Santa Clara County Health Department, Centers for Disease Control and CCLD website.

No deficiency was cited. A copy of this report was provided to licensee for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020
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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