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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202705
Report Date: 05/21/2021
Date Signed: 05/28/2021 01:21:19 PM

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:CRESCENT OAKSFACILITY NUMBER:
435202705
ADMINISTRATOR:SANDOVAL, GRACEFACILITY TYPE:
740
ADDRESS:147 CRESCENT AVETELEPHONE:
(408) 730-4004
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:44CENSUS: 26DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Grace SandovalTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Administrator (ADM) Grace Sandoval.

LPA toured the facility with ADM. One central entry point was designated for all staff, residents, and visitors. A screening station, sign in sheet, and COVID-19 questionnaire were present at the entrance.

All staff members were observed to be wearing masks.

COVID-19 signs were present throughout the facility and hand washing signs in the restrooms. All restrooms observed to be adequately stocked with paper towels and hand soap. Hand sanitizer stations were observed to be available throughout the facility.

Facility observed to have adequate supply of Personal Protective Equipment (PPE) in the storage rooms. A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) was in file.

No deficiency cited during visit. However, an advisory note was issued, see LIC 9102.

This report was reviewed with ADM and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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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