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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202583
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:55:49 PM


Document Has Been Signed on 09/21/2022 04:55 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:JESSIE COURT CARE HOMEFACILITY NUMBER:
435202583
ADMINISTRATOR:VU, KRISTINE ABLAOFACILITY TYPE:
740
ADDRESS:2934 JESSIE COURTTELEPHONE:
(408) 628-4702
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 5DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:KRISTINE ABLAOTIME COMPLETED:
04:20 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) KRISTINE ABLAO. Upon arrival, ADM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, family room, kitchen, dining room and three restrooms were inspected. Some trash cans were observed without covers. ADM stated ADM will put all the trash cans with covers in 5 days. Paper towels were observed with holders. Restrooms did not have the posters of washing hands for 20 seconds. ADM stated ADM will put the posters of washing hands for 20 seconds in restrooms and kitchen in 5 days. 5 single resident bedrooms, 2 staff live-in rooms and laundry room were observed. 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 110 degree F in facility. 5 residents and 2 staff were observed in facility.

Fire extinguisher was serviced on 09/05/2022. 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. A swimming pool was observed in the back yard. The swimming pool was with fences and was locked. LPA reviewed the 5 resident file binders. The resident files are up to date.

ADM stated all the residents and staff are fully vaccinated and done with booster. ADM stated the facility already submitted the Infection Control Plan to CCL Office. No citation were noted today. Exit interview was conducted with ADM. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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