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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202649
Report Date: 12/28/2022
Date Signed: 12/28/2022 03:18:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/28/2022 03:18 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:SVS SAN JOSE INCLUSION CENTERFACILITY NUMBER:
435202649
ADMINISTRATOR:PERKINS, CYNTHIAFACILITY TYPE:
775
ADDRESS:1304 SARATOGA AVETELEPHONE:
(408) 574-3950
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 60CENSUS: 8DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley LanfrancoTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Program Director (PD) Ashley Lanfranco.

Upon arrival, PD took LPA temperature, and logged LPA in the visitor log book. LPA observed the COVID posters on the main door. LPA toured the whole facility with PD.

Offices, conference room, computer Lab, visitor room, activity rooms, restrooms, kitchens, game room, storages rooms, Garden room, and Exercise room were observed and inspected. All the trash cans were observed with covers. All the sinks in restrooms and in kitchens were observed with posters of washing hands for 20 seconds. All paper towels were observed with holders.

PPE supplies were observed sufficient. Room temperature was 72 degree F. The facility was equipped with smoke and carbon monoxide detectors. Smoke detector alarm system was tested, and was working fine. Fire extinguisher was serviced on 8/11/2022. Front yard and backyard were inspected. There was no obstruction to block the walkways.

PD stated all staff are fully vaccinated and done with boosters. The facility already submitted Infection Control Plan to LPA.

Exit interview was conducted with PD, No citation was noted for today visit. This report was provided to PD.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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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