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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202592
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:29:37 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/26/2022 04:29 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:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Bonnie CoddTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manger (HM) Bonnie Codd. Upon arrival, Staff Alexandra Orosco(AO) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside and out with AO. 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, office, kitchen, dinning room and three restrooms were inspected. Trash cans were observed with covers. Paper towels were observed with holders. Posters of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. Four single resident bedrooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 70 degree F, and hot water temperature was at 107 degree F in facility. Two residents and two staff were observed in facility.

Fire extinguisher was serviced on 2/14/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by AO, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

AO stated the facility already submitted the Infection Control Plan to CCL office. No citation were noted today. Exit interview was conducted with HM. This report was provided to HM
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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