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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202592
Report Date: 10/26/2021
Date Signed: 11/01/2021 03:10:07 PM

Document Has Been Signed on 11/01/2021 03:10 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:FOOTHILL ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
435202592
ADMINISTRATOR:ANGELICA ATRIANOFACILITY TYPE:
735
ADDRESS:13655 FOOTHILL AVETELEPHONE:
(669) 231-3861
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 4CENSUS: 3DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Angelica AtrianoTIME COMPLETED:
01:00 PM
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On 10/26/2021 at 10:40 am, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced Annual Required 1 Year visit. LPA met with staff Valerie Flores. Administrator Angelica Atriano joined LPA in the middle of the tour.

LPA toured the facility beginning with the main entrance. The entrance had a thermometer, hand sanitizer, and sign-in log. Temperature was taken and screening questions were asked. Screening questions were not asked or documented for staff. LPA recommended COVID-19 screening questions to be asked and documented for staff. Facility is taking daily resident and staff temperatures.

Universal precautions, COVID-19 protocols, and social distancing guidelines were posted throughout the facility. Restrooms had hand soap and paper towels readily available. LPA observed step trash cans in all restrooms. Facility had at least 30-day supply of medications for the residents.

Staff were observed wearing a mask and following COVID-19 protocols. Facility observed to have adequate supply of PPE.

An advisory note was issued, please see LIC 9102. No deficiencies were cited during today's visit.

This report and advisory note were reviewed with Administrator Angelica Atriano and copies were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Anna Bui
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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