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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202631
Report Date: 07/29/2022
Date Signed: 07/29/2022 03:05:35 PM


Document Has Been Signed on 07/29/2022 03:05 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:MINA'S ELDERLY CARE HOME 4FACILITY NUMBER:
435202631
ADMINISTRATOR:GIMENO, MICHAELFACILITY TYPE:
740
ADDRESS:215 CASTILLON WAYTELEPHONE:
(408) 622-8257
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY:6CENSUS: 5DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Mina AbbasvandTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Mina Abbasvand. Upon arrival, Staff Esther Diapen (S1) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and in the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Family room, kitchen, dinning room and two restrooms were inspected. Some trash cans were observed without covers. ADM stated the facility will put all the trash cans with covers in 3 days. Paper towels were observed without holders in restrooms. ADM stated the facility will put all the paper towels with holders in 3 days. Two shared resident bedrooms, two resident single rooms, and laundry room were inspected. One staff live-in room was observed in facility. The beds in shared rooms were observed in 6 feet apart. Cloth towels were observed in kitchen. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 74 degree F, and hot water temperature was at 108 degree F in facility. Five residents and two staff were observed in facility.

Fire extinguisher was serviced on 02/22/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with boosters. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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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