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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202616
Report Date: 03/02/2022
Date Signed: 03/03/2022 08:25:13 AM


Document Has Been Signed on 03/03/2022 08:25 AM - 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,
, CA



FACILITY NAME:KEENE KAREFACILITY NUMBER:
435202616
ADMINISTRATOR:GAMBOA, ABIGAILFACILITY TYPE:
740
ADDRESS:2488 GLEN ELM WAYTELEPHONE:
(408) 531-9678
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 4DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Abigail GamboaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Abigail Gamboa Administrator.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies and medications are secured in locked cabinets in the laundry room.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products. Hand Washing signs posted in the bathrooms and in the kitchen near the sinks. Foot operated trash containers are used in the kitchen and bathrooms. Hand sanitizer available to visitors and residents. LPA observed supply of Personal Protective Equipment (PPE) and PPE Cart. COVID 19 signs posted included Wear a Mask, Visitor Policy, COVID 19 Screening Symptom Questionnaire, Cough Etiquette, How Can I Protect Myself, Self Monitor, PPE Donning and Doffing and Social Distancing.

LPA reviewed the facility policies and procedures to include visitation, screening, masking, isolation and disinfecting.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Abigail Gamboa Administrator and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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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