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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202633
Report Date: 03/02/2022
Date Signed: 03/03/2022 08:21:46 AM

Document Has Been Signed on 03/03/2022 08:21 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:EDGEVIEW MANORFACILITY NUMBER:
435202633
ADMINISTRATOR:CAPALLA, SHARI LYNNFACILITY TYPE:
735
ADDRESS:1989 EDGEVIEW DRIVETELEPHONE:
(408) 677-3563
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 5DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shari Lynn CapallaTIME COMPLETED:
02:00 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 Shari Lynn Capalla.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the family 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. Covered trash containers observed in the kitchen and bathrooms. Hand sanitizer available to visitors and residents. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Stop Must Wear a Mask, Face Mask Required, Visitor Policy, COVID Screening Symptoms, Cough Etiquette, Symptoms to Watch For, Self Monitor and Practice, Germs and Cleaning for COVID 19.

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 Shari Lynn Capalla and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
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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