<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202643
Report Date: 01/04/2023
Date Signed: 01/04/2023 03:57:15 PM


Document Has Been Signed on 01/04/2023 03:57 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: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:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Amarjeet Mann, ADMTIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Amarjeet Mann.

Upon Arrival, ADM took LPA's body temperature, and checked LPA in the visitor log book. LPA observed the COVID posters in the facility. One staff and six residents were observed in facility.

LPA toured the facility inside and out with ADM. LPA inspected living room, family room, dinning room, kitchen. There are 3 restrooms, 6 resident single rooms, and 1 staff live-in room in facility. Trash cans were observed with covers in facility. Posters of washing hands for 20 seconds were observed by the sinks in restroom and in kitchen. Paper towels were observed with holders. Two days perishable foods and seven non perishable foods were observed sufficient. Room temperature was observed at 74 degree F, hot water temperature was observed at 113 degree F. Medication cabinet, Knife closet, and cleaning products closet were observed locked. PPE supplies were observed sufficient. Fire extinguisher was serviced on 10/06/2022. The facility was equipped with smoke and carbon monoxide detectors. Smoke detector alarm system was tested, and was 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 booster shots. ADM already submitted the Infection Control Plan to LPA.

No deficiency or allegation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1