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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202594
Report Date: 09/09/2022
Date Signed: 09/09/2022 12:16:51 PM

Document Has Been Signed on 09/09/2022 12:16 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:COMMUNITY SOLUTIONS CRISIS RESIDENTIALFACILITY NUMBER:
435202594
ADMINISTRATOR:VICKI PACHECOFACILITY TYPE:
772
ADDRESS:115 MADRONE AVENUETELEPHONE:
(669) 888-3182
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 15CENSUS: 11DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Vicki PachecoTIME COMPLETED:
12:20 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 Administrator, Vicki Pacheco and Program Supervisor, Angelica Suud.

During visit, LPA toured the facility to include the bedrooms, bathrooms, office, medication room, laundry room, kitchen, and backyard. All fire exits routes were free and clear of obstruction. Butter knife observed in the backyard and secured immediately. All staff observed wearing a face covering. Facility temperature was maintained between 72 to 75 degrees Fahrenheit. LPA observed the facility has 2 days worth of perishables and 7 days worth of non-perishable foods.

Facility has a designated symptom screening and temperature check for all visitors, staff, and clients. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplied with hygiene products and hand washing sign. Paper towel dispensers observed throughout the facility next to a trash can with lid. Facility clean and disinfect multiple times daily and as needed. LPA observed facility's Personal Protective Equipment (PPE) supplies and isolation cart to include PPE supplies. LPA reviewed the facility's procedures to isolation. Staff was last N95 fit tested in 2020 and have not renewed the fit-testing this year. Facility was advised to complete Infection Control training this year, and when needed. The following signs observed to include mask required, protect yourself from COVID, limit the spread of germs, social distancing, and donning and doffing PPE.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Vicki Pacheco, Angelica Suud, and Director of Quality Assurance and Compliance, Chris Mullins and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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