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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202656
Report Date: 12/28/2022
Date Signed: 12/28/2022 03:24:53 PM

Document Has Been Signed on 12/28/2022 03:24 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MOUNT BLUE RESIDENTIAL CARE HOME INCFACILITY NUMBER:
435202656
ADMINISTRATOR:FREDRICKA SAFARFACILITY TYPE:
735
ADDRESS:1233 BRYAN AVETELEPHONE:
(415) 385-8900
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 6DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Licensee/ Administrator Fredricka SafarTIME COMPLETED:
03:30 PM
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On 12/28/2022 at 2:20pm, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual required inspection and met with Staff, Gracelyn Gatus and Licensee/ Administrator (ADM) Fredricka Safar.

During visit, LPA Rai toured the facility to include the family room, dining room, 3 bedrooms, 3 bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff observed wearing a face covering.

Facility has a designated entry point for sign-in, symptom screening, and temperature check for all visitors and staff. Hand sanitizer made available at entry and throughout the facility. Visitation guidelines posted at the entrance. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. LPA Rai observed facility's Personal Protective Equipment (PPE) supplies. ADM will replenish the PPE supplies and keep 30 day supply at the facility. Facility has procedures to isolation and testing for COVID-19. Staff are trained on infection control. Facility staff clean and disinfect multiple times daily and as needed. The following posters observed to include wash your hands, symptoms of COVID-19 and wear face mask.

Per ADM, the staff are not N95 fit tested, ADM will contact Concentra or a Health clinic for staff to be N95 fit tested. LPA Rai observed a no visitor sign posted at the front door. Staff removed the no visitor sign during visit. LPA Rai advised of the visitation guidelines per PIN 22-28.1-ASC.

No deficiencies were cited per California Code of Regulations, Title 22. Technical Assistance notes were provided.

This report was reviewed with Licensee/ Administrator Fredricka Safar and a copy of the report was provided. ADM gave permission for Staff Gracelyn Gatus to sign document on her behalf.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
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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