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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202629
Report Date: 11/19/2021
Date Signed: 11/19/2021 03:42:05 PM

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:BLENDED FAMILY CARE HOMEFACILITY NUMBER:
435202629
ADMINISTRATOR:PAGKALINAWAN, MICHELLEFACILITY TYPE:
740
ADDRESS:10366 MILLER AVENUETELEPHONE:
(408) 802-6410
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:12CENSUS: 9DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:PAGKALINAWAN, MICHELLETIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA) Christine Dolores conducted an unannounced annual required inspection. LPA met with Administrator Michelle Pagkalinawan.

During today's visit LPA toured the facility inside and outside to include living room, dining room, kitchen, hallways, bathrooms, resident rooms, and backyard. LPA observed a central entry point to include a screening station for visitors and hand sanitizer.

LPA observed the following posters to include, cough etiquette, hand washing, feeling ill, and COVID-19 symptom warning. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces daily and as needed.

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, staffing, training, PPE supplies, N95 fit testing, and social distancing.

LPA Dolores will provide additional COVID-19 resources to include donning and doffing.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Michelle Pagkalinawan, Administrator and copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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