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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202651
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:15:04 PM

Document Has Been Signed on 03/28/2022 04:15 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:MERIDIAN MANOR IVFACILITY NUMBER:
435202651
ADMINISTRATOR:EMMANUEL G FERNANDOFACILITY TYPE:
735
ADDRESS:1502 CONSTANSO WAYTELEPHONE:
(408) 882-3908
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 3CENSUS: 3DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:EMMANUEL G FERNANDOTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) EMMANUEL G FERNANDO. Upon arrival, staff Evangeliae Abela (EA) took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. Living room, office, kitchen, dinning room and two restrooms were inspected. Trash cans were observed with covers. Cloth towels were observed in kitchen. ADM removed the cloth towels in kitchen, and placed more paper towels in kitchen. Paper towels were observed with holders. Three single resident bedrooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 69 degree F, and hot water temperature was at 110 degree F in facility. Three residents and two staff were observed in facility.

Fire extinguisher was serviced on 07/09/2021. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by staff. The smoke detectors were 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. ADM stated all staff and residents are done with booster except one resident. No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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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