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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202696
Report Date: 02/07/2022
Date Signed: 02/07/2022 04:08:32 PM

Document Has Been Signed on 02/07/2022 04:08 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:HOLLY'S CARE HOMEFACILITY NUMBER:
435202696
ADMINISTRATOR:ANA LUISA MEJIAFACILITY TYPE:
735
ADDRESS:531 CANTON DRIVETELEPHONE:
(408) 224-3159
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
02/07/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Ana Luisa MejiaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager Sarah Yip, and Nurse Lori Kopplinger conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Ana Luisa Mejia.

Administrator Ana Luisa Mejia reports that there are currently 0 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by Nurse Lori Kopplinger:

1. Post sign at entrance with list of COVID symptoms
2. Add place to record temperatures on visitor screening forms
3. Record staff symptoms as well as temperatures
4. Use foot-operated lidded trash can in bathrooms
5. Fit test staff for N95 masks
6. Place available fruit in kitchen area in a container
7. Use disinfectant with a two minute or less contact time

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Ana Luisa Mejia. A copy of the report will be sent to her for to be signed and returned to CCL.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
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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