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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202666
Report Date: 06/27/2022
Date Signed: 06/27/2022 02:52:12 PM


Document Has Been Signed on 06/27/2022 02:52 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:TOUCH OF LIFE RESIDENTIAL CARE FACILITY INCFACILITY NUMBER:
435202666
ADMINISTRATOR:DEVANO, BELINDAFACILITY TYPE:
740
ADDRESS:2748 ASHLEY CTTELEPHONE:
(408) 854-0735
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:6CENSUS: 4DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Belinda DevanoTIME COMPLETED:
02:53 PM
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Licensing Program Analysts Ryker Heberle (LPA) conducted an unannounced annual inspection on 06/27/2022 at 01:51pm. LPA met with facility Administrator Belinda Devano (Admin).

LPA toured the facility, including living room, kitchen, dining room, laundry room, 4 resident bedrooms, 3 staff bedrooms, 4 bathrooms, garage and back yard. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility Mitigation plan has already been submitted. 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. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be last inspected in June 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors tested and observed to be operational.

Facility observed to have designated entry point. Staff took LPAs' temperature and screened for symptoms. 30 days supply of PPE was observed. Hand washing signs were observed in facility bathrooms. Paper towels were observed in resident bathrooms. Water temperature observed to be 105.0 *F in facility bathroom. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with Administrator Belinda Devano 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: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
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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