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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202587
Report Date: 06/23/2022
Date Signed: 06/23/2022 04:24:34 PM

Document Has Been Signed on 06/23/2022 04:24 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:GREEN VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202587
ADMINISTRATOR:VAKILI, MEHDIFACILITY TYPE:
735
ADDRESS:10512 DUKE DRIVETELEPHONE:
(408) 841-3992
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Toribia Piscasio and Tayebeh SedighTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection to focus on infection control. LPA met with caregiver, Toribia "Belen" Piscasio and Administrator, Tayebeh Sedigh.

During visit, LPA toured the facility to include the entrance, kitchen, living room, activity room, bathrooms, resident rooms, staff rooms, garage, and backyard. All fire exit rooms were free and clear of obstruction. Toxins and sharp objects were secured. Medication stored in a locked cabinet.

Facility has a designated entry point to include a sign-in sheet. Administrator stated to be working on a COVID-19 symptom screening log for visitors. Staff monitor and document their symptoms and temperature daily and as needed. Staff monitor and document the residents symptoms and temperature daily and as needed. Bathrooms supplies with hygiene products, paper supplies, and hand washing sign. Facility staff clean and disinfects daily and as needed. LPA observed supply of Personal Protective Equipment (PPE). Staff are N95 fit tested. All staff observed wearing a face covering. LPA reviewed the facility's procedures to isolation and infection control training. The following posters observed to include limit the spread of germs, symptoms of COVID, and droplet precaution.

LPA observed a no visitor sign posted at the front door. Staff removed the no visitor sign during visit. LPA advised of the visitation guidelines per PIN 22-07-ASC.

LPA requested for the updated LIC500, LIC610D, and change of Administrator documents by 07/01/2022.

No citations issued per California Code of Regulations, Title 22. Advisory notes provided.
This report was reviewed with the Administrator and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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