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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202664
Report Date: 06/29/2022
Date Signed: 06/29/2022 04:34:36 PM


Document Has Been Signed on 06/29/2022 04:34 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:MINA'S ELDERLY CARE HOME 3 LLCFACILITY NUMBER:
435202664
ADMINISTRATOR:ABBASVAND, MINAFACILITY TYPE:
740
ADDRESS:427 RICHLEE DRTELEPHONE:
(408) 272-7946
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:6CENSUS: 6DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Mina AbbasvandTIME COMPLETED:
04:35 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 06/29/2022 at 3:40pm. LPA met with facility administrator Mina Abbasvand (Admin).

LPA toured the facility including, front hallway, 3 bathrooms, kitchen, dining room, living room, 5 resident bedrooms, medicine/PPE cabinet, and porch visitation area.

Admin confirmed that all residents and staff have been vaccinated. Facility infectious control plan has already been submitted and is pending approval. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility water temperature observed to be 107.8*F. Fire extinguisher noted to have received inspection in September 2021. Smoke detectors observed to be operational. Facility observed to have 2 days supply of perishable food and 1 weeks supply of non-perishable food.

Facility observed to have designated entry point for universal symptom screening with questionnaire. All restrooms observed to be adequately stocked with paper towels, hand sanitizer, and hand soap. Bathrooms observed to have foot operated trash cans. Facility observed to have adequate supply of PPE.

No deficiencies cited during this inspection. This report reviewed with Administrator Mina Abbasvand and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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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