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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202643
Report Date: 01/29/2021
Date Signed: 01/29/2021 05:47:53 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:AMY'S RESIDENTIAL CARE, INC.FACILITY NUMBER:
435202643
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:671 N WHITE RDTELEPHONE:
(408) 898-8784
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 6DATE:
01/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amarjeet MannTIME COMPLETED:
11:50 AM
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At 11:00AM, Licensing Program Analyst (LPA) Steve Chang and Health Facilities Evaluator Nurse Barbara Elenteny conducted a Tele Visit with PCC via zoom platform. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with administrator (ADM) Amarjeet Mann. ADM stated she is a nurse, and the facility will have COVID test today. ADM stated the facility had vaccination on 1/27/2021, and will have vaccination on 2/17/2021 and 3/3/2021. ADM stated the 6 resident rooms are all single rooms.

During today's inspection, facility was virtually toured. The facility has COVID-19 related signs posted at the main entrance. Facility has hand sanitizer, thermometer, and sign-in log with questionnaire at the main entrance. Signs of keeping social distancing were posted at the common area, Living room, and dinning room. Hand washing signs, hand sanitizers, and paper towel with holder were observed at restrooms and kitchen. Some of the trash cans without cover with foot pedal were observed. PPE supplies, cleaning product supplies, and food supplies were checked. The facility has sufficient supplies for PPE, cleaning products, and food.

The following are the recommendations:
1. Remove the cloth towel in the restrooms.
2. Trash can should have cover (foot pedal).
3. Remove extra chairs at the dinning room.

No deficiency was cited during today's tele visit. A copy of this report emailed to facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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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