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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202696
Report Date: 11/01/2022
Date Signed: 11/01/2022 04:36:27 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/01/2022 04:36 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: 6DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Gina De Vera, HMTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Gina De Vera . Upon arrival, HM took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside and out with HM. COVID posters were observed at main entrance. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, family room, kitchen, dinning room and three restrooms were inspected. All trash cans were observed with covers. Paper towels were observed with holders. Three resident bedrooms, and laundry room were inspected. Three staff live-in rooms are in facility. 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 68 degree F, and hot water temperature was at 106 degree F in facility. Six residents and 3 staff were observed in facility.

Fire extinguisher was serviced on 01/14/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

HM stated all the residents and staff are fully vaccinated and done with booster. HM stated the facility already submitted the Infection Control Plan to CCL office.

No citation were noted today. Exit interview was conducted with HM. This report was provided to HM for signature. A copy of this report was provided to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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