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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202644
Report Date: 09/21/2021
Date Signed: 09/30/2021 11:05:05 AM

Document Has Been Signed on 09/30/2021 11:05 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CARING HANDS RESIDENTIAL LIVINGFACILITY NUMBER:
435202644
ADMINISTRATOR:OKORO, SYLVESTERFACILITY TYPE:
740
ADDRESS:3590 ROLLINGSIDE DRTELEPHONE:
(408) 440-0200
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 3DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tinyan IgbinigieTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit. LPA met with the Caregiver Tinyan Igbinigie.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station and sign in sheet were present at the entrance. LPA was temperature screened before entering.

LPA toured the facility. The facility was observed to be in sanitary condition. There were hand sanitizers at the entrance and in the facility. LPA inspected the residents' restroom. The restroom was observed to be adequately stocked with paper towels, hand soap, and a covered trash bin. Hand washing sign was present.

A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) from the facility was submitted and approved. LPA discussed the infection control with Caregiver. LPA reviewed the current Provider Information Notice PIN 21-40-ASC with Caregiver. All residents and all staff were fully vaccinated per Caregiver.

No deficiency cited during visit. However, advisory notes were issued. See LIC 9102s.

This report was reviewed with Caregiver. A copy of this report were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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